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                                                                 EXHIBIT (10)(d)
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PLATINUM INVESTOR III                                                                                        AMERICAN
VARIABLE UNIVERSAL LIFE INSURANCE                                                                               |GENERAL
SUPPLEMENTAL APPLICATION                                                                                        |FINANCIAL GROUP

AMERICAN GENERAL LIFE INSURANCE COMPANY,  ("AGL")
Home Office: Houston, TX

Member of American General Financial Group. American General Financial Group is the marketing name for American General Corporation
and its subsidiaries.

(This supplement must accompany the appropriate application for life insurance.)
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APPLICANT INFORMATION - SUPPLEMENT TO THE APPLICATION ON THE LIFE OF
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Name of proposed insured                                                    Date of application for life insurance

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INITIAL ALLOCATION PERCENTAGES
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INVESTMENT OPTIONS    In the "Premium Allocation" column, indicate how each premium received is to be allocated. In the "Deduction
                      Allocation" column, indicate which investment options are to be used for the deduction of monthly charges.
                      Total allocations in each column must equal 100%. Use whole percentages only.

                                           PREMIUM    DEDUCTION                                               PREMIUM    DEDUCTION
                                          ALLOCATION  ALLOCATION                                             ALLOCATION  ALLOCATION
                                          ----------  ----------                                             ----------  ----------
AIM VARIABLE INSURANCE FUNDS                                      NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST
AIM V.I. International Growth Division (260)_____%     _____%     Mid-Cap Growth Division (286)                    _____%     ____%
AIM V.I. Premier Equity Division (261)      _____%     _____%
                                                                  PIMCO VARIABLE INSURANCE TRUST
AMERICAN CENTURY VARIABLE PORTFOLIOS, INC.                        PIMCO Real Return Division (288)                 _____%     _____%
VP Value Division (262)                     _____%     _____%     PIMCO Short-Term Division (287)                  _____%     _____%
                                                                  PIMCO Total Return Division (289)                _____%     _____%
AYCO SERIES TRUST
Ayco Growth Division (270)                  _____%     _____%     PUTNAM VARIABLE TRUST
                                                                  Putnam VT Diversified Income Division (290)      _____%     _____%
CREDIT SUISSE TRUST                                               Putnam VT Growth and Income Division (291)       _____%     _____%
Small Cap Growth Division (300)             _____%     _____%     Putnam VT Int'l Growth and Income Division (292) _____%     _____%

DREYFUS INVESTMENT PORTFOLIOS                                     SAFECO RESOURCE SERIES TRUST
MidCap Stock Division (273)                 _____%     _____%     Equity Division (293)                            _____%     _____%
                                                                  Growth Opportunities Division (294)              _____%     _____%
DREYFUS VARIABLE INVESTMENT FUND
Quality Bond Division (271)                 _____%     _____%     SUNAMERICA SERIES TRUST
Small Cap Division (272)                    _____%     _____%     SunAmerica Balanced Division (306)               _____%     _____%
                                                                  Aggressive Growth Division (307)                 _____%     _____%
FIDELITY VARIABLE INSURANCE PRODUCTS FUND
VIP Asset Manager Division (277)            _____%     _____%     THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
VIP Contrafund Division (276)               _____%     _____%     Equity Growth Division (295)                     _____%     _____%
VIP Equity-Income Division (274)            _____%     _____%     High Yield Division (296)                        _____%     _____%
VIP Growth Division (275)                   _____%     _____%
                                                                  VALIC COMPANY I
FRANKLIN TEMPLETON VARIABLE INSURANCE PRODUCTS TRUST              International Equities Division (263)            _____%     _____%
Franklin U.S. Government Division (302)     _____%     _____%     Mid Cap Index Division (264)                     _____%     _____%
Mutual Shares Securities Division (303)     _____%     _____%     Money Market I Division (265)                    _____%     _____%
Templeton Foreign Securities Division (304) _____%     _____%     Nasdaq-100 Index Division (266)                  _____%     _____%
                                                                  Science & Technology Division (269)              _____%     _____%
JANUS ASPEN SERIES                                                Small Cap Index Division (268)                   _____%     _____%
Aggressive Growth Division (280)            _____%     _____%     Stock Index Division (267)                       _____%     _____%
International Growth Division (278)         _____%     _____%
Worldwide Growth Division (279)             _____%     _____%     VANGUARD VARIABLE INSURANCE FUND
                                                                  High Yield Bond Division (297)                   _____%     _____%
J.P. MORGAN SERIES TRUST II                                       REIT Index Division (298)                        _____%     _____%
JPMorgan Small Company Division (281)       _____%     _____%
                                                                  VAN KAMPEN LIFE INVESTMENT TRUST
MFS VARIABLE INSURANCE TRUST                                      Growth & Income Division (305)                   _____%     _____%
MFS Capital Opportunities Division (284)    _____%     _____%
MFS Emerging Growth Division (282)          _____%     _____%     AGL DECLARED FIXED INTEREST ACCOUNT (301)        _____%     _____%
MFS New Discovery Division (285)            _____%     _____%     OTHER:_____________________________              _____%     _____%
MFS Research Division (283)                 _____%     _____%                                                       100%       100%
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AGLC 0198-00                                                                                                            Page  1 of 4
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DOLLAR COST AVERAGING
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DOLLAR COST    ($5,000 MINIMUM BEGINNING ACCUMULATION VALUE) An amount can be systematically transferred from the Money Market I
AVERAGING      Division and transferred to one or more of the investment options below. The AGL Declared Fixed Interest Account is
               not available for Dollar Cost Averaging. Please refer to the prospectus for more information on the Dollar Cost
               Averaging option.

               Day of the month for transfers:                         (Choose a day of the month between 1-28.)
               _____________________________________________________   _________________________________________
               Frequency of transfers:  [_] Monthly    [_] Quarterly    [_] Semiannually   [_] Annually
               _______________________  ___________    _____________    _________________  _______________
               Transfer $                                              ($100 MINIMUM, WHOLE DOLLARS ONLY)
               ___________________________________________             ___________________________________

AIM VARIABLE INSURANCE FUNDS                                     NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST
AIM V.I. International Growth Division (260) $__________         Mid-Cap Growth Division (286)                       $__________
AIM V.I. Premier Equity Division (261)       $__________
                                                                 PIMCO VARIABLE INSURANCE TRUST
AMERICAN CENTURY VARIABLE PORTFOLIOS, INC.                       PIMCO Real Return Division (288)                    $__________
VP Value Division (262)                      $__________         PIMCO Short-Term Division (287)                     $__________
                                                                 PIMCO Total Return Division (289)                   $__________
AYCO SERIES TRUST
Ayco Growth Division (270)                   $__________         PUTNAM VARIABLE TRUST
                                                                 Putnam VT Diversified Income Division (290)         $__________
CREDIT SUISSE TRUST                                              Putnam VT Growth and Income Division (291)          $__________
Small Cap Growth Division (300)              $__________         Putnam VT Int'l Growth and Income Division (292)    $__________

DREYFUS INVESTMENT PORTFOLIOS                                    SAFECO RESOURCE SERIES TRUST
MidCap Stock Division (273)                  $__________         Equity Division (293)                               $__________
                                                                 Growth Opportunities Division (294)                 $__________
DREYFUS VARIABLE INVESTMENT FUND
Quality Bond Division (271)                  $__________         SUNAMERICA SERIES TRUST
Small Cap Division (272)                     $__________         SunAmerica Balanced Division (306)                  $__________
                                                                 Aggressive Growth Division (307)                    $__________
FIDELITY VARIABLE INSURANCE PRODUCTS FUNDS
VIP Asset Manager Division (277)             $__________         THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
VIP Contrafund Division (276)                $__________         Equity Growth Division (295)                        $__________
VIP Equity-Income Division (274)             $__________         High Yield Division (296)                           $__________
VIP Growth Division (275)                    $__________
                                                                 VALIC COMPANY I
FRANKLIN TEMPLETON VARIABLE INSURANCE PRODUCTS TRUST             International Equities Division (263)               $__________
Franklin U.S. Government Division (302)      $__________         Mid Cap Index Division (264)                        $__________
Mutual Shares Securities Division (303)      $__________         Nasdaq-100 Index Division (266)                     $__________
Templeton Foreign Securities Division (304)  $__________         Science & Technology Division (269)                 $__________
                                                                 Small Cap Index Division (268)                      $__________
JANUS ASPEN SERIES                                               Stock Index Division (267)                          $__________
Aggressive Growth Division (280)             $__________
International Growth Division (278)          $__________         VANGUARD VARIABLE INSURANCE FUND
Worldwide Growth Division (279)              $__________         High Yield Bond Division (297)                      $__________
                                                                 REIT Index Division (298)                           $__________
J.P. MORGAN SERIES TRUST II
JPMorgan Small Company Division (281)        $__________         VAN KAMPEN LIFE INVESTMENT TRUST
                                                                 Growth & Income Division (305)                      $__________
MFS VARIABLE INSURANCE TRUST
MFS Capital Opportunities Division (284)     $__________         OTHER:_______________________________               $__________
MFS Emerging Growth Division (282)           $__________
MFS New Discovery Division (285)             $__________
MFS Research Division (283)                  $__________
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AUTOMATIC REBALANCING
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AUTOMATIC      ($5,000 MINIMUM BEGINNING ACCUMULATION VALUE) Variable division assets will be automatically rebalanced based on the
REBALANCING    premium percentages designated on Page 1 of this form. If the AGL Declared Fixed Interest Account has been designated
               for premium allocation, the rebalancing will be based on the proportion allocated to the variable divisions. Please
               refer to the prospectus for more information on the Automatic Rebalancing option.

               CHECK HERE FOR AUTOMATIC REBALANCING FREQUENCY:  [_] Quarterly  [_] Semiannually  [_] Annually
               ----------------------------------------------   -------------  ----------------  -----------
               NOTE: Automatic Rebalancing is not available if the Dollar Cost Averaging option has been chosen.

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MODIFIED ENDOWMENT CONTRACT
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CONTRACT       If any premium payment causes the policy to be classified as a modified endowment contract under Section 7702A of the
               Internal Revenue Code, there may be potentially adverse tax consequences. Such consequences include: (1) withdrawals
               or loans being taxed to the extent of gain; and (2) a 10% penalty tax on the taxable amount. In order to avoid
               modified endowment status, I request any excess premium that could cause such status to be refunded.
                                                                                                         [_] YES   [_] NO
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AGLC 0198-00                                                                                                             Page 2 of 4
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DEATH BENEFIT COMPLIANCE TEST
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                           [_] Guideline Premium Test                           [_] Cash Value Accumulation Test

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SPECIFIED AMOUNT
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Base Coverage $______________________plus Supplemental Coverage $ _________________________ = Total Specified Amount $ _____________

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TELEPHONE AUTHORIZATION
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                      I (or we, if Joint Owners), hereby authorize American General Life Insurance Company ("AGL") to act on
                      telephone instructions to transfer values among the variable divisions and the AGL Declared Fixed Interest
                      Account and to change allocations for future premium payments and monthly deductions given by:

INITIAL APPROPRIATE   [    ]  Policy Owner(s)- if Joint Owners, either of us acting independently.
BOX HERE:
                      [    ]  Policy Owner(s) or the Agent/Registered Representative who is appointed to represent AGL and the firm
                              authorized to service my policy.

                      AGL and any person designated by this authorization will not be responsible for any claim, loss or expense
                      based upon telephone instructions received and acted on in good faith, including losses due to telephone
                      instruction communication errors. AGL's liability for erroneous transfers and allocations, unless clearly
                      contrary to instructions received, will be limited to correction of the allocations on a current basis. If an
                      error, objection or other claim arises due to a telephone transaction, I will notify AGL in writing within
                      five working days from receipt of confirmation of the transaction from AGL. I understand that this
                      authorization is subject to the terms and provisions of my variable universal life insurance policy and its
                      related prospectus. This authorization will remain in effect until my written notice of its revocation is
                      received by AGL at its home office.

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SUITABILITY
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ALL QUESTIONS MUST    1. Have you, the Proposed Insured or Owner (if different), received the variable universal life
BE ANSWERED:             insurance policy prospectus and the prospectuses describing the investment options?         [_] yes  [_] no

                         (IF "YES," PLEASE FURNISH THE PROSPECTUS DATES.)

                             Variable Universal Life Insurance Policy Prospectus:     __________

                             Supplements (if any):                                    __________

                      2. Do you understand and acknowledge:

                         a. THAT THE POLICY APPLIED FOR IS VARIABLE, EMPLOYS THE USE OF SEGREGATED ACCOUNTS WHICH
                            MEANS THAT YOU NEED TO RECEIVE AND UNDERSTAND CURRENT PROSPECTUSES FOR THE POLICY AND
                            THE UNDERLYING ACCOUNTS?                                                                 [_] yes  [_] no

                         b. THAT ANY BENEFITS, VALUES OR PAYMENTS BASED ON PERFORMANCE OF THE SEGREGATED
                            ACCOUNTS MAY VARY: AND                                                                   [_] yes  [_] no

                            (1)  ARE NOT GUARANTEED BY THE COMPANY, ANY OTHER INSURANCE COMPANY, THE U.S.
                                 GOVERNMENT OR ANY STATE GOVERNMENT?                                                 [_] yes  [_] no

                            (2)  ARE NOT FEDERALLY INSURED BY THE FDIC, THE FEDERAL RESERVE BOARD OR ANY
                                 OTHER AGENCY, FEDERAL OR STATE?                                                     [_] yes  [_] no

                         c. THAT IN ESSENCE, ALL RISK IS BORNE BY THE OWNER EXCEPT FOR FUNDS PLACED IN
                            THE AGL DECLARED FIXED INTEREST ACCOUNT?                                                 [_] yes  [_] no

                         d. THAT THE POLICY IS DESIGNED TO PROVIDE LIFE INSURANCE COVERAGE AND TO ALLOW FOR
                            THE ACCUMULATION OF VALUES IN THE SEGREGATED ACCOUNTS?                                   [_] yes  [_] no

                         e. THE AMOUNT OR DURATION OF THE DEATH BENEFIT MAY INCREASE OR DECREASE, DEPENDING
                            ON THE INVESTMENT EXPERIENCE OF THE SEPARATE ACCOUNT?                                    [_] yes  [_] no

                         f. THE POLICY VALUES MAY INCREASE OR DECREASE, DEPENDING ON THE INVESTMENT
                            EXPERIENCE OF THE SEPARATE ACCOUNT, THE AGL DECLARED FIXED INTEREST ACCOUNT
                            ACCUMULATION, AND CERTAIN EXPENSE DEDUCTIONS?                                            [_] yes  [_] no

                      3. Do you believe the Policy you selected meets your insurance and investment
                         objectives and your anticipated financial needs?                                            [_] yes  [_] no
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AGLC 0198-00                                                                                                             Page 3 of 4
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YOUR SIGNATURE
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SIGNATURES   Signed at (city, state)
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             Print name of Broker/Dealer
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             X Registered representative                                      State license #                   Date
             ------------------------------------------------------------------------------------------------   --------------------

             X Primary proposed insured                                                                         Date
             ------------------------------------------------------------------------------------------------   -------------------

             X Owner                                                                                            Date
             ------------------------------------------------------------------------------------------------   -------------------
             (If different from Proposed Insured)

             X Joint Owner                                                                                      Date
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             (If applicable)
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AGLC 0198-00                                                                                                           Page 4 of 4
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                                                                   EXHIBIT 10(e)

----------------------------------
|                SERVICE REQUEST |
----------------------------------

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     P   L   A   T   I   N   U   M
----------------------------------
                  INVESTOR(SM) III
----------------------------------
             AMERICAN GENERAL LIFE
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PLATINUM INVESTOR III--FIXED OPTION                                 MFS Variable Insurance Trust
     .  Division 301 -- AGL Declared Fixed Interest Account         ----------------------------
                                                                         .  Division 284 - MFS Capital Opportunities
PLATINUM INVESTOR III -- VARIABLE DIVISIONS                              .  Division 282 - MFS Emerging Growth
AIM Variable Insurance Funds                                             .  Division 285 - MFS New Discovery
----------------------------                                             .  Division 283 - MFS Research
     .  Division 260 - AIM V.I. International Growth
     .  Division 261 - AIM V.I. Premier Equity                      Neuberger Berman Advisers Management Trust
                                                                    ------------------------------------------
American Century Variable Portfolios, Inc.                               .  Division 286 - Mid-Cap Growth
------------------------------------------
     .  Division 262 - VP Value                                     PIMCO Variable Insurance Trust
                                                                    ------------------------------
Ayco Series Trust                                                        .  Division 288 - PIMCO Real Return
-----------------                                                        .  Division 287 - PIMCO Short-Term
     .  Division 270 - Ayco Growth                                       .  Division 289 - PIMCO Total Return

Credit Suisse Trust                                                 Putnam Variable Trust
-------------------                                                 ---------------------
     .  Division 300 - Small Cap Growth                                  .  Division 290 - Putnam VT Diversified Income
                                                                         .  Division 291 - Putnam VT Growth and Income
Dreyfus Investment Portfolios                                            .  Division 292 - Putnam VT Int'l Growth and Income
-----------------------------
     .  Division 273 - MidCap Stock                                 SAFECO Resource Series Trust
                                                                    ----------------------------
Dreyfus Variable Investment Fund                                         .  Division 293 - Equity
--------------------------------                                         .  Division 294 - Growth Opportunities
     .  Division 271 - Quality Bond
     .  Division 272 - Small Cap                                    SUNAMERICA SERIES TRUST
                                                                         .  Division 307 - Aggressive Growth
Fidelity Variable Insurance Products Fund                                .  Division 306 - SunAmerica Balanced
-----------------------------------------
     .  Division 277 - VIP Asset Manager                            The Universal Institutional Funds, Inc.
     .  Division 276 - VIP Contrafund                               ---------------------------------------
     .  Division 274 - VIP Equity-Income                                 .  Division 295 - Equity Growth
     .  Division 275 - VIP Growth                                        .  Division 296 - High Yield

Franklin Templeton Variable Insurance Products Trust                VALIC Company I
----------------------------------------------------                ---------------
     .  Division 302 - Franklin U.S. Government                          .  Division 263 - International Equities
     .  Division 303 - Mutual Shares Securities                          .  Division 264 - MidCap Index
     .  Division 304 - Templeton Foreign Securities                      .  Division 265 - Money Market I
                                                                         .  Division 266 - Nasdaq-100 Index
Janus Aspen Series                                                       .  Division 269 - Science & Technology
------------------                                                       .  Division 268 - Small Cap Index
     .  Division 280 - Aggressive Growth                                 .  Division 267 - Stock Index
     .  Division 278 - International Growth
     .  Division 279 - Worldwide Growth                             Vanguard Variable Insurance Fund
                                                                    --------------------------------
J.P. Morgan Series Trust II                                              .  Division 297 - High Yield Bond
---------------------------                                              .  Division 298 - REIT Index
     .  Division 281 - JPMorgan Small Company
                                                                    Van Kampen Life Investment Trust
                                                                    --------------------------------
                                                                         .  Division 299 - Growth & Income
AGLC0223 Rev 0302
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AIG  AMERICAN                                                                                                VARIABLE UNIVERSAL LIFE
       |GENERAL                                                                                            INSURANCE SERVICE REQUEST

                                                                                                COMPLETE AND RETURN THIS REQUEST TO:
                                                                                                  Variable Universal Life Operations
AMERICAN GENERAL LIFE INSURANCE COMPANY ("AGL")                                                  PO Box 4880.Houston, TX. 77210-4880
Member of American International Group, Inc.
                                      (888) 325-9315 or (713) 831-3443 . Hearing Impaired (TDD) (888) 436-5258 . Fax: (877) 445-3098
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  [_]  POLICY                  1. | POLICY #:_________________________________ Insured:__________________________________
       IDENTIFICATION             | Address:________________________________________________________________ New Address (yes) (no)
    COMPLETE THIS SECTION         | Primary Owner (if other than an insured):_______________________________
      FOR ALL REQUESTS.           | Address:________________________________________________________________ New Address (yes) (no)
                                  | Primary Owner's S.S. No. or Tax I.D. No._____________ Phone Number:(   )_____-_________________
                                  | Joint Owner (if applicable):___________________________________________________________________
                                  | Address:________________________________________________________________ New Address (yes) (no)
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  [_]  NAME                    2. | Change Name Of: (Circle One)    Insured    Owner   Payor   Beneficiary
       CHANGE                     |
Complete this section if the name | Change Name From: (First, Middle, Last)               Change Name To: (First, Middle, Last)
of one of the Contingent Insureds,| __________________________________________________    __________________________________________
Owner, Payor or Beneficiary has   |
changed. (Please note, this does  | Reason for Change: (Circle One) Marriage Divorce Correction Other (Attach copy of legal proof)
    not change the Contingent     |
   Insureds, Owner, Payor or      |
   Beneficiary designation.)      |
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  [_]  CHANGE IN               3. | INVESTMENT DIVISION               PREM % DED %   INVESTMENT DIVISION               PREM %  DED %
       ALLOCATION                 | AIM VARIABLE INSURANCE FUNDS                     NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST
       PERCENTAGES                | (260) AIM V.I. International Growth _____ _____  (286) Mid-Cap Growth             ______  ______
  Use this section to indicate    | (261) AIM V.I. Premier Equity       _____ _____
     how premiums or monthly      |                                                  PIMCO VARIABLE INSURANCE TRUST
 deductions are to be allocated.  | AMERICAN CENTURY VARIABLE                        (288) PIMCO Real Return          ______  ______
 Total allocation in each column  | PORTFOLIOS, INC.                                 (287) PIMCO Short-Term           ______  ______
     must equal 100%; whole       | (262) VP Value                      _____ _____  (289) PIMCO Total Return         ______  ______
         numbers only.            |
                                  | AYCO SERIES TRUST                                PUTNAM VARIABLE TRUST
                                  | (270) Ayco Growth                   _____ _____  (290) Putnam VT Diversified
                                  |                                                        Income                     ______  ______
                                  | CREDIT SUISSE TRUST                              (291) Putnam VT Growth and Income______  ______
                                  | (300) Small Cap Growth              _____ _____  (292) Putnam VT Int'l Growth and
                                  |                                                        Income                     ______  ______
                                  | DREYFUS INVESTMENT PORTFOLIOS
                                  | (273) MidCap Stock                  _____ _____  SAFECO RESOURCE SERIES TRUST
                                  |                                                  (293) Equity                     ______  ______
                                  | DREYFUS VARIABLE INVESTMENT FUND                 (294) Growth Opportunities       ______  ______
                                  | (271) Quality Bond                  _____ _____
                                  | (272) Small Cap                     _____ _____  SUNAMERICA SERIES TRUST
                                  |                                                  (307) Aggressive Growth          ______  ______
                                  | FIDELITY VARIABLE INSURANCE                      (306) SunAmerica Balanced        ______  ______
                                  | PRODUCTS FUND
                                  | (277) VIP Asset Manager             _____ _____  THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
                                  | (276) VIP Contrafund                _____ _____  (295) Equity Growth              ______  ______
                                  | (274) VIP Equity-Income             _____ _____  (296) High Yield                 ______  ______
                                  | (275) VIP Growth                    _____ _____
                                  |                                                  VALIC COMPANY I
                                  | FRANKLIN TEMPLETON VARIABLE                      (263) International Equities     ______  ______
                                  | INSURANCE PRODUCTS TRUST                         (264) Mid Cap Index              ______  ______
                                  | (302) Franklin U.S. Government      _____ _____  (265) Money Market I             ______  ______
                                  | (303) Mutual Shares Securities      _____ _____  (266) Nasdaq-100 Index           ______  ______
                                  | (304) Templeton Foreign Securities  _____ _____  (269) Science & Technology       ______  ______
                                  |                                                  (268) Small Cap Index            ______  ______
                                  | JANUS ASPEN SERIES                               (267) Stock Index                ______  ______
                                  | (280) Aggressive Growth             _____ _____
                                  | (278) International Growth          _____ _____  VANGUARD VARIABLE INSURANCE FUND
                                  | (279) Worldwide Growth              _____ _____  (297) High Yield Bond            ______  ______
                                  |                                                  (298) REIT Index                 ______  ______
                                  | J.P MORGAN SERIES TRUST II
                                  | (281) JPMorgan Small Company        _____ _____  VAN KAMPEN LIFE INVESTMENT TRUST
                                  |                                                  (299) Growth & Income            ______  ______
                                  | MFS VARIABLE INSURANCE TRUST
                                  | (284) MFS Capital Opportunities     _____ _____  Other:_______________________    ______  ______
                                  | (282) MFS Emerging Growth           _____ _____  (301) AGL Declared Fixed
                                  | (285) MFS New Discovery             _____ _____        Interest Account           ______  ______
                                  | (283) MFS Research                  _____ _____                                   100%    100%
                                  |
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AGLC0223 Rev0302                                               PAGE 2 OF 5
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  [_]  MODE OF                 4. | Indicate frequency and premium amount desired: $______ Annual $_____ Semi-Annual $____ Quarterly
       PREMIUM                    |                                                $_____ Monthly (Bank Draft Only)
       PAYMENT/BILLING            |
       METHOD CHANGE              | Indicate billing method desired: _____Direct Bill  _____Pre-Authorized Bank Draft (attach a
  Use this section to change the  |                                                         Bank Draft Authorization Form and
 billing frequency and/or method  |                                                         "Void" Check)
  of premium payment.  Note,      |
however, that AGL will not bill   | Start Date: ________/ _______/ _________
   you on a direct monthly basis. |
 Refer to your policy and its     |
 related prospectus for further   |
 information concerning minimum   |
  premiums and billing options.   |
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  [_]  LOST POLICY             5. | I/we hereby certify that the policy of insurance for the listed policy has been
       CERTIFICATE                |  ______LOST ______DESTROYED ______OTHER.
Complete this section if applying |
for a Certificate of Insurance or | Unless I/we have directed cancellation of the policy, I/we request that a:
 duplicate policy to replace a    |
 lost or misplaced policy. If a   |             _______Certificate of Insurance at no charge
 full duplicate policy is being   |
requested, a check or money order |             _______Full duplicate policy at a charge of $25
 for $25 payable to AGL must be   |
  submitted with this request.    | be issued to me/us. If the original policy is located, I/we will return the Certificate
                                  | or duplicate policy to AGL for cancellation.
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  [_]  DOLLAR COST             6. | Designate the day of the month for transfers: _______(choose a day from 1-28)
       AVERAGING                  | Frequency of transfers (check one): _____Monthly _____Quarterly _____Semi-Annually _____Annually
     ($5,000 minimum initial      | I want: $________________ ($100 minimum) taken from the Money Market I Division and
accumulation value) An amount may | transferred to the following Divisions:
be deducted periodically from the |
  Money Market I Division and     | AIM VARIABLE INSURANCE FUNDS                    NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST
  placed in one or more of the    | (260) AIM V.I. International Growth   $_______  (286) Mid-Cap Growth                    $_______
        divisions listed.         | (261) AIM V.I. Premier Equity         $_______
     The AGL Declared Fixed       |                                                 PIMCO VARIABLE INSURANCE TRUST
Interest Account is not available | AMERICAN CENTURY VARIABLE PORTFOLIOS, INC.      (288) PIMCO Real Return                 $_______
    for Dollar Cost Averaging.    | (262) VP Value                        $_______  (287) PIMCO Short-Term                  $_______
 Please refer to the prospectus   |                                                 (289) PIMCO Total Return                $_______
   for more information on the    | AYCO SERIES TRUST
  Dollar Cost Averaging Option.   | (270) Ayco Growth                     $_______  PUTNAM VARIABLE TRUST
    Note: Automatic Rebalancing   |                                                 (290) Putnam VT Diversified Income      $_______
  is not available if the Dollar  | CREDIT SUISSE TRUST                             (291) Putnam VT Growth and Income       $_______
    Cost Averaging Option is      | (300) Small Cap Growth                $_______  (292) Putnam VT Int'l Growth and Income $_______
           chosen.                |
                                  | DREYFUS INVESTMENT PORTFOLIOS                    SAFECO RESOURCE SERIES TRUST
                                  | (273) MidCap Stock                    $_______   (293) Equity                           $_______
                                  |                                                  (294) Growth Opportunities             $_______
                                  | DREYFUS VARIABLE INVESTMENT FUND
                                  | (271) Quality Bond                    $_______   SUNAMERICA SERIES TRUST
                                  | (272) Small Cap                       $_______   (307) Aggressive Growth                $_______
                                  |                                                  (306) SunAmerica Balanced              $_______
                                  | FIDELITY VARIABLE INSURANCE PRODUCTS FUND
                                  | (277) VIP Asset Manager               $_______   THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
                                  | (276) VIP Contrafund                  $_______   (295) Equity Growth                    $_______
                                  | (274) VIP Equity-Income               $_______   (296) High Yield                       $_______
                                  | (275) VIP Growth                      $_______
                                  |                                                  VALIC COMPANY I
                                  | FRANKLIN TEMPLETON VARIABLE INSURANCE            (263) International Equities           $_______
                                  | PRODUCTS TRUST                                   (264) Mid Cap Index                    $_______
                                  | (302) Franklin U.S. Government        $_______   (266) Nasdaq-100 Index                 $_______
                                  | (303) Mutual Shares Securities        $_______   (269) Science & Technology             $_______
                                  | (304) Templeton Foreign Securities    $_______   (268) Small Cap Index                  $_______
                                  |                                                  (267) Stock Index                      $_______
                                  | JANUS ASPEN SERIES
                                  | (280) Aggressive Growth               $_______   VANGUARD VARIABLE INSURANCE FUND
                                  | (278) International Growth            $_______   (297) High Yield Bond                  $_______
                                  | (279) Worldwide Growth                $_______   (298) REIT Index                       $_______
                                  |
                                  | J.P. MORGAN SERIES TRUST II                      VAN KAMPEN LIFE INVESTMENT TRUST
                                  | (281) JPMorgan Small Company          $_______   (299) Growth & Income                  $_______
                                  |
                                  | MFS VARIABLE INSURANCE TRUST                     OTHER:_____________________________    $_______
                                  | (284) MFS Capital Opportunities       $_______
                                  | (282) MFS Emerging Growth             $_______
                                  | (285) MFS New Discovery               $_______
                                  | (283) MFS Research Division           $_______
                                  | _______ INITIAL HERE TO REVOKE DOLLAR COST AVERAGING ELECTION.
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AGLC0223 Rev0302                                               PAGE 3 OF 5
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  [_]  AUTOMATIC               7. |
       REBALANCING                | Indicate frequency: ________Quarterly ________Semi-Annually ________Annually
   ($5,000 minimum accumulation   |
 value) Use this section to apply |              (DIVISION NAME OR NUMBER)                        (DIVISION NAME OR NUMBER)
      for or make changes to      |
   Automatic Rebalancing of the   | _________%:___________________________________      ________%:________________________________
 variable divisions. Please refer |
    to the prospectus for more    | _________%:___________________________________      ________%:________________________________
   information on the Automatic   |
       Rebalancing Option.        | _________%:___________________________________      ________%:________________________________
 Note: Dollar Cost Averaging is   |
 not available if the Automatic   | _________%:___________________________________      ________%:________________________________
  Rebalancing Option is chosen.   |
                                  | _________%:___________________________________      ________%:________________________________
                                  |
                                  | _________%:___________________________________      ________%:________________________________
                                  |
                                  | _________%:___________________________________      ________%:________________________________
                                  |
                                  | _________%:___________________________________      ________%:________________________________
                                  |
                                  | _________%:___________________________________      ________%:________________________________
                                  |
                                  | _________%:___________________________________      ________%:________________________________
                                  |
                                  | _________%:___________________________________      ________%:________________________________
                                  |
                                  | ______________Initial Here To Revoke Automatic Rebalancing Election.
                                  |
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  [_]  TELEPHONE               8. | I(/we if Joint Owners) hereby authorize AGL to act on telephone instructions to transfer values
       PRIVILEGE                  | among the Variable Divisions and AGL Declared Fixed Interest Account and to change allocations
       AUTHORIZATION              | for future purchase payments and monthly deductions.
Complete this section if you are  |
applying for or revoking current  | Initial the designation you prefer:
     telephone privileges.        |
                                  | _________Policy Owner(s) ONLY - If Joint Owners, either one acting independently.
                                  |
                                  | _________Policy Owner(s) OR Agent/Registered Representative who is appointed to represent AGL
                                  |          and the firm authorized to service my policy.
                                  |
                                  | AGL and any non-owner designated by this authorization will not be responsible for any claim,
                                  | loss or expense based upon telephone transfer or allocation instructions received and acted upon
                                  | in good faith, including losses due to telephone instruction communication errors. AGL's
                                  | liability for erroneous transfers or allocations, unless clearly contrary to instructions
                                  | received, will be limited to correction of the allocations on a current basis. If an error,
                                  | objection or other claim arises due to a telephone transaction, I will notify AGL in writing
                                  | within five working days from the receipt of the confirmation of the transaction from AGL. I
                                  | understand that this authorization is subject to the terms and provisions of my variable
                                  | universal life insurance policy and its related prospectus. This authorization will remain in
                                  | effect until my written notice of its revocation is received by AGL at the address printed on
                                  | the top of this service request form.
                                  |
                                  | _______INITIAL HERE TO REVOKE TELEPHONE PRIVILEGE AUTHORIZATION.
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 [_]  CORRECT AGE              9. |
 Use this section to correct the  | Name of Insured for whom this correction is submitted: ______________________________
 age of any person covered under  |
this policy. Proof of the correct | Correct DOB: _________/____________ /_____________
date of birth must accompany this |
            request.              |
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 [_]  TRANSFER OF             10. |                                     (DIVISION NAME OR NUMBER)         (DIVISION NAME OR NUMBER)
      ACCUMULATED                 |
      VALUES                      | Transfer $_______ or _______% from ____________________________ to ____________________________.
  Use this section if you want to |
   move money between divisions.  | Transfer $_______ or _______% from ____________________________ to ____________________________.
The minimum amount for transfers  |
is $500.00. Withdrawals from the  | Transfer $_______ or _______% from ____________________________ to ____________________________.
  AGL Declared Fixed Interest     |
Account to a Variable Division    | Transfer $_______ or _______% from ____________________________ to ____________________________.
may only be made within the 60    |
days after a contract anniversary.| Transfer $_______ or _______% from ____________________________ to ____________________________.
See transfer limitations outlined |
 in prospectus. If a transfer     | Transfer $_______ or _______% from ____________________________ to ____________________________.
      causes the balance in       |
   any division to drop below     | Transfer $_______ or _______% from ____________________________ to ____________________________.
 $500, AGL reserves the right     |
to transfer the remaining balance.| Transfer $_______ or _______% from ____________________________ to ____________________________.
 Amounts to be transferred should |
    be indicated in dollar or     | Transfer $_______ or _______% from ____________________________ to ____________________________.
  percentage amounts, maintaining |
     consistency throughout.      | Transfer $_______ or _______% from ____________________________ to ____________________________.
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AGLC0233 Rev0302                                                     PAGE 4 OF 5
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 [_]  REQUEST FOR PARTIAL     11. | _______ I request a partial surrender of $________ or _______% of the net cash surrender value.
      SURRENDER/POLICY LOAN       |
                                  | _______ I request a loan in the amount of $__________.
 Use this section to apply for a  |
partial surrender from or policy  | _______ I request the maximum loan amount available from my policy.
loan against policy values. For   |
detailed information concerning   | Unless you direct otherwise below, proceeds are allocated according to the deduction allocation
 these two options please refer   | percentages in effect, if available; otherwise they ar taken pro-rata from the AGL Declared
 to your policy and its related   | Fixed Interest Account and Variable Divisions in use.
 prospectus. If applying for a    |
 partial surrender, be sure to    | _______________________________________________________________________________________________
   complete the Notice of         |
 Withholding section of this      | _______________________________________________________________________________________________
Service Request in addition to    |
        this section.             | _______________________________________________________________________________________________
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 [_]  NOTICE OF               12. | The taxable portion of the distribution you receive from your variable universal life insurance
      WITHHOLDING                 | policy is subject to federal income tax withholding unless you elect not to have withholding
Complete this section if you have | apply. Withholding of state income tax may also be required by your state of residence. You may
 applied for a partial surrender  | elect not to have withholding apply by checking the appropriate box below. If you elect not to
        in Section 11.            | have withholding apply to your distribution or if you do not have enough income tax withheld,
                                  | you may be responsible for payment of estimated tax. You may incur penalties under the
                                  | estimated tax rules, if your withholding and estimated tax are not sufficient.
                                  |
                                  | Check one: ________I DO want income tax withheld from this distribution.
                                  |
                                  |            ________I DO NOT want income tax withheld from this distribution.
                                  |
                                  | IF NO ELECTION IS MADE, WE ARE REQUIRED TO WITHHOLD FEDERAL INCOME TAX (IF APPLICABLE).
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 [_]  AFFIRMATION/            13. | CERTIFICATION: UNDER PENALTIES OF PERJURY, I CERTIFY: (1) THAT THE NUMBER SHOWN ON THIS FORM IS
      SIGNATURE                   | MY CORRECT TAXPAYER IDENTIFICATION NUMBER AND; (2) THAT I AM NOT SUBJECT TO BACKUP WITHHOLDING
   Complete this section for      | UNDER SECTION 3406(a)(1)(c) OF THE INTERNAL REVENUE CODE.
         ALL requests.            |
                                  | THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS DOCUMENT
                                  | OTHER THAN THE CERTIFICATION REQUIRED TO AVOID BACKUP WITHHOLDING.
                                  |
                                  |
                                  |
                                  | Dated at_______________this___________day of______________________________________,__________
                                  |         CITY, STATE
                                  |
                                  |
                                  | X______________________________________________   X__________________________________________
                                  |  SIGNATURE OF OWNER                                SIGNATURE OF WITNESS
                                  |
                                  | X______________________________________________   X__________________________________________
                                  |  SIGNATURE OF JOINT OWNER                          SIGNATURE OF WITNESS
                                  |
                                  | X______________________________________________   X__________________________________________
                                  |  SIGNATURE OF ASSIGNEE
                                  |
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AGLC0223 Rev0302                                                PAGE 5 OF 5
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