Document:

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                                                                 EXHIBIT (10)(d)

            SERVICE REQUEST

                   PLATINUM
---------------------------
      INVESTOR/SM/ SURVIVOR
---------------------------
      AMERICAN GENERAL LIFE

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PLATINUM INVESTOR SURVIVOR II--FIXED OPTION                     MFS Variable Insurance Trust
                                                                ----------------------------
 . Division 18 - AGL Declared Fixed Interest Account
                                                                . Division 165 - MFS Capital Opportunities
PLATINUM INVESTOR SURVIVOR II--VARIABLE DIVISIONS
                                                                . Division 141 - MFS Emerging Growth
AIM Variable Insurance Funds
----------------------------                                    . Division 166 - MFS New Discovery

 . Division 130 - AIM V.I. International Equity                  . Division 164 - MFS Research

 . Division 131 - AIM V.I. Value                                 Neuberger Berman Advisers Management Trust
                                                                ------------------------------------------
American Century Variable Portfolios. Inc.
------------------------------------------                      . Division 167 - Mid-Cap Growth

 . Division 153 - VP Value                                       PIMCO Variable Insurance Trust
                                                                ------------------------------
Ayco Series Trust
-----------------                                               . Division 169 - PIMCO Real Return Bond

 . Division 154 - Ayco Growth                                    . Division 168 - PIMCO Short-Term Bond

Credit Suisse Warburg Pincus Trust                              . Division 170 - PIMCO Total Return Bond
----------------------------------
                                                                Putnam Variable Trust
 . Division 173 - Small Company Growth                           ---------------------

Dreyfus Investment Portfolios                                   . Division 144 - Putnam VT Diversified Income
-----------------------------
                                                                . Division 145 - Putnam VT Growth and Income
 . Division 155 - MidCap Stock
                                                                . Division 146 - Putnam VT Int'l Growth and Income
Dreyfus Variable Investment Fund
--------------------------------                                SAFECO Resource Series Trust
                                                                ----------------------------
 . Division 139 - Quality Bond
                                                                . Division 147 - Equity
 . Division 140 - Small Cap
                                                                . Division 148 - Growth Opportunities
Fidelity Variable Insurance Products Fund
-----------------------------------------                       The Universal Institutional Funds, Inc.
                                                                ---------------------------------------
 . Division 159 - VIP Asset Manager
                                                                . Division 142 - Equity Growth
 . Division 158 - VIP Contrafund
                                                                . Division 143 - High Yield
 . Division 157 - VIP Equity-Income
                                                                VALIC Company I
 . Division 156 - VIP Growth                                     ---------------

Franklin Templeton Variable Insurance Products Trust            . Division 132 - International Equities
----------------------------------------------------
                                                                . Division 133 - Mid Cap Index
 . Division 174 - Franklin U.S. Government
                                                                . Division 134 - Money Market I
 . Division 175 - Mutual Shares Securities
                                                                . Division 136 - Nasdaq-100 Index
 . Division 176 - Templeton International Securities
                                                                . Division 137 - Science & Technology
Janus Aspen Series
------------------                                              . Division 138 - Small Cap Index

 . Division 162 - Aggressive Growth                              . Division 135 - Stock Index

 . Division 160 - International Growth                           Vanguard Variable Insurance Fund
                                                                -------------------------------
 . Division 161 - Worldwide Growth
                                                                . Division 171 - High Yield Bond
J.P. Morgan Series Trust II
---------------------------                                     . Division 172 - REIT Index

 . Division 163 - J.P. Morgan Small Company                      Van Kampen Life Investment Trust
                                                                --------------------------------

                                                                . Division 149 - Strategic Stock

AGLC0463 REV 1101
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 Complete and return this request to:        American General Life Insurance Company ("AGL")                AMERICAN
  Variable Universal Life Operations              Member American General Financial Group                       GENERAL
 PO Box 4880 Houston, TX 77210-4880                         Houston, Texas                                      FINANCIAL GROUP
  (888) 325-9315 or (713) 831-3443
        Fax: (877) 445-3098
Hearing Impaired/TDD: (888) 436-5258           VARIABLE UNIVERSAL LIFE INSURANCE SERVICE REQUEST

------------------------------------------------------------------------------------------------------------------------------------
  [_]  POLICY                  1. | POLICY #:_________________________________ CONTINGENT INSURED:__________________________________
       IDENTIFICATION             |                                            CONTINGENT INSURED: _________________________________
    COMPLETE THIS SECTION FOR     | ADDRESS:________________________________________________________________ New Address (yes) (no)
        ALL REQUESTS.             | Primary Owner (if other than an insured):_______________________________
                                  | 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)     Contingent 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                 | (18) AGL DECLARED FIXED INTEREST                 NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST
       PERCENTAGES                |      ACCOUNT                        _____ _____  (167) Mid-Cap Growth               _____ _____
  Use this section to indicate    | AIM VARIABLE INSURANCE FUNDS
     how premiums or monthly      | (130) AIM V.I. International Equity _____ _____  PIMCO VARIABLE INSURANCE TRUST
 deductions are to be allocated.  | (131) AIM V.I. Value                _____ _____  (169) PIMCO Real Return Bond       _____ _____
 Total allocation in each column  |                                                  (168) PIMCO Short-Term Bond        _____ _____
     must equal 100%; whole       | AMERICAN CENTURY VARIABLE PORTFOLIOS, INC.       (170) PIMCO Total Return Bond      _____ _____
         numbers only.            | (153) VP Value                      _____ _____
                                  |                                                  PUTNAM VARIABLE TRUST
                                  | AYCO SERIES TRUST                                (144) Putnam VT Diversified Income _____ _____
                                  | (154) Ayco Growth                   _____ _____  (148) Putnam VT Growth and Income  _____ _____
                                  |                                                  (146) Putnam VT Int'l Growth and
                                  | CREDIT SUISSE WARBURG PINCUS TRUST                       Income                     _____ _____
                                  | (173) Small Company Growth          _____ _____
                                  |                                                  SAFECO RESOURCE SERIES TRUST
                                  | DREYFUS INVESTMENT PORTFOLIOS                    (147) Equity                       _____ _____
                                  | (155) Midcap Stock                  _____ _____  (148) Growth Opportunities         _____ _____
                                  |
                                  | DREYFUS VARIABLE INVESTMENT FUND                 THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
                                  | (139) Quality Bond                  _____ _____  (142) Equity Growth                _____ _____
                                  | (140) Small Cap                     _____ _____  (143) High Yield                   _____ _____
                                  |
                                  | FIDELITY VARIABLE INSURANCE PRODUCTS FUND        VALIC COMPANY I
                                  | (159) VIP Asset Manager             _____ _____  (132) International Equities       _____ _____
                                  | (158) VIP Contrafund                _____ _____  (133) Mid Cap Index                _____ _____
                                  | (156) VIP Equity-Income             _____ _____  (134) Money Market I               _____ _____
                                  | (157) VIP Growth                    _____ _____  (136) Nasdaq-100 Index             _____ _____
                                  |                                                  (137) Science & Technology         _____ _____
                                  | FRANKLIN TEMPLETON VARIABLE INSURANCE            (138) Small Cap Index              _____ _____
                                  |  PRODUCTS TRUST                                  (135) Stock Index                  _____ _____
                                  | (174) Franklin U.S. Government      _____ _____
                                  | (175) Mutual Shares Securities      _____ _____  VANGUARD VARIABLE INSURANCE FUND
                                  | (176) Templeton International       _____ _____  (171) High Yield Bond              _____ _____
                                  |       Securities                                 (172) REIT Index                   _____ _____
                                  |
                                  | JANUS ASPEN SERIES                               VAN KAMPEN LIFE INVESTMENT TRUST
                                  | (162) Aggressive Growth             _____ _____  (149) Strategic Stock              _____ _____
                                  | (160) International Growth          _____ _____
                                  | (161) Worldwide Growth              _____ _____  OTHER:_______________________      _____ _____
                                  |
                                  | J.P MORGAN SERIES TRUST II                                                           100%  100%
                                  | (163) J.P Morgan Small Company      _____ _____
                                  |
                                  | MFS VARIABLE INSURANCE TRUST
                                  | (165) MFS Capital Opportunities     _____ _____
                                  | (141) MFS Emerging Growth           _____ _____
                                  | (166) MFS New Discovery             _____ _____
                                  | (164) MFS Research                  _____ _____
                                  |
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AGLCO463 REV 1101                                              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 "Void"  Check)
 billing frequency and/or method  |
  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, whole dollars only) taken from the Money Market I
accumulation value) An amount may | Division and transferred to the following Divisions:
be deducted periodically from the |
Money Market I Division and placed| (18) AGL DECLARED FIXED INTEREST                MFS VARIABLE INSURANCE TRUST
  in one or more of the Divisions |      ACCOUNT                         $________  (165) MFS Capital Opportunities        $________
 listed. The AGL Declared Fixed   |                                                 (141) MFS Emerging Growth              $________
Interest Account is not available | AIM VARIABLE INSURANCE FUNDS                    (166) MFS New Discovery                $________
for Dollar Cost Averaging. Please | (130) AIM V.I. International Equity  $________  (164) MFS Research                     $________
refer to the prospectus for more  | (131) AIM V.I. Value                 $________
 information on the Dollar Cost   |                                                 NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST
Averaging Option. Note: Automatic | AMERICAN CENTURY VARIABLE PORTFOLIOS            (167) Mid-Cap Growth                   $________
 Rebalancing is not available if  | (153) VP Value                       $________
the Dollar Cost Averaging Option  |                                                 PIMCO VARIABLE INSURANCE TRUST
          is chosen.              | AYCO SERIES TRUST                               (169) PIMCO Real Return Bond           $________
                                  | (154) Ayco Growth                    $________  (168) PIMCO Short-Term Bond            $________
                                  |                                                 (170) PIMCO Total Return Bond          $________
                                  | CREDIT SUISSE WARBURG PINCUS TRUST
                                  | (173) Small Company Growth           $________  PUTNAM VARIABLE TRUST
                                  |                                                 (144) Putnam VT Diversified Income     $________
                                  | DREYFUS INVESTMENT PORTFOLIOS                   (145) Putnam VT Growth and Income      $________
                                  | (155) Midcap Stock                   $________  (146) Putnam VT Int'l Growth and
                                  |                                                       Income                           $________
                                  | DREYFUS VARIABLE INVESTMENT FUND
                                  | (139) Quality Bond                   $________  SAFECO Resource Series Trust
                                  | (140) Small Cap                      $________  (147) Equity                           $________
                                  |                                                 (148) Growth Opportunities             $________
                                  | FIDELITY VARIABLE INSURANCE PRODUCTS FUND
                                  | (159) VIP Asset Manager              $________  THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
                                  | (158) VIP Contrafund                 $________  (142) Equity Growth                    $________
                                  | (156) VIP Equity-Income              $________  (143) High Yield                       $________
                                  | (157) VIP Growth                     $________
                                  |                                                 VALIC COMPANY I
                                  | FRANKLIN TEMPLETON VARIABLE INSURANCE           (132) International Equities           $________
                                  |  PRODUCTS TRUST                                 (133) Mid Cap Index                    $________
                                  | (174) Franklin U.S. Government       $________  (136) Nasdaq-100 Index                 $________
                                  | (175) Mutual Shares Securities       $________  (137) Science & Technology             $________
                                  | (176) Templeton International                   (138) Small Cap Index                  $________
                                  |       Securities                     $________  (135) Stock Index                      $________
                                  |
                                  | JANUS ASPEN SERIES                              VANGUARD VARIABLE INSURANCE FUND
                                  | (162) Aggressive Growth              $________  (171) High Yield Bond                  $________
                                  | (160) International Growth           $________  (172) REIT Index                       $________
                                  | (161) Worldwide Growth               $________
                                  |                                                 VAN KAMPEN LIFE INVESTMENT TRUST
                                  | J.P. MORGAN SERIES TRUST II                     (149) Strategic Stock                  $________
                                  | (163) J.P. Morgan Small Company      $________  OTHER: ____________________________    $________
                                  |
                                  | _____ INITIAL HERE TO REVOKE DOLLAR COST AVERAGING ELECTION
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AGLC0463 REV 1101                                              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. | Name of Contingent Insured for whom this correction is submitted:_______________________________
 Use this section to correct the  |
 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 60 days  |
after a contract anniversary. See | Transfer $_______ or _______% from ____________________________ to _____________________________
 transfer limitations outlined in |
 prospectus. If a transfer causes | Transfer $_______ or _______% from ____________________________ to _____________________________
  the balance in any division to  |
  drop below $500, AGL reserves   | Transfer $_______ or _______% from ____________________________ to _____________________________
      the right to transfer       |
 the remaining balance. Amounts   | Transfer $_______ or _______% from ____________________________ to _____________________________
    to be transferred should be   |
 indicated in dollar a percentage | Transfer $_______ or _______% from ____________________________ to _____________________________
    amounts, maintaining          |
   consistency throughout.        | Transfer $_______ or _______% from ____________________________ to _____________________________
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AGLC0463 REV 1101                                                   PAGE 4 OF 5
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 [_]  REQUEST FOR             11. |
      PARTIAL                     | ______I request a partial surrender of $_____ or _____% of the net cash surrender value.
      SURRENDER/                  | ______I request a loan in the amount of $_____.
      POLICY LOAN                 | ______I request the maximum loan amount available from my policy.
 Use this section to apply for a  |
 partial surrender from or policy |
 loan against policy values. For  | Unless you direct otherwise below, proceeds are allocated according to the deduction allocation
 detailed information concerning  | percentages in effect, if available; otherwise they are taken pro-rata from the AGL Declared
these two options please refer to | Fixed Interest Account and Variable Divisions in use.
   your policy and its related    |
  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 it 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/            10. | 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                             SIGNATURE OF WITNESS
                                  |
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AGLCO463 REV 1101                                              PAGE 5 OF 5
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                                                                 EXHIBIT (10)(f)

                                                              AMERICAN
                                                                |GENERAL
                                                                |FINANCIAL GROUP
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<CAPTION>

PLATINUM INVESTOR SURVIVOR II
JOINT AND LAST SURVIVOR VARIABLE UNIVERSAL
LIFE INSURANCE SUPPLEMENTAL APPLICATION

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

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 lives of
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<S>                                            <C>                                           <C>

------------------------------------------     -----------------------------------------     --------------------------------------
Name of Proposed Contingent Insured            Name of Other Proposed Contingent 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
                                          ----------  ----------                                             ----------  ----------
AGL Declared Fixed Interest Account (18)     _____%     _____%    NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST
                                                                  Mid-Cap Growth Division (167)                    _____%     _____%
AIM VARIABLE INSURANCE FUNDS
AIM V.I. International Equity Division (130) _____%     _____%    PIMCO VARIABLE INSURANCE TRUST
AIM V.I. Value Division (131)                _____%     _____%    PIMCO Real Return Bond Division (169)            _____%     _____%
                                                                  PIMCO Short-Term Bond Division (168)             _____%     _____%
AMERICAN CENTURY VARIABLE PORTFOLIOS, INC.                        PIMCO Total Return Bond Division (170)           _____%     _____%
VP Value Division (153)                      _____%     _____%
                                                                  PUTNAM VARIABLE TRUST
AYCO SERIES TRUST                                                 Putnam VT Diversified Income Division (144)      _____%     _____%
Ayco Growth Division (154)                   _____%     _____%    Putnam VT Growth and Income Division (145)       _____%     _____%
                                                                  Putnam VT Int'I Growth and Income Division (146) _____%     _____%
CREDIT SUISSE WARBURG PINCUS TRUST
Small Company Growth Division (173)          _____%     _____%    SAFECO RESOURCE SERIES TRUST
                                                                  Equity Division (147)                            _____%     _____%
DREYFUS INVESTMENT PORTFOLIOS                                     Growth Opportunities Division (148)              _____%     _____%
MidCap Stock Division (155)                  _____%     _____%
                                                                  THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
DREYFUS VARIABLE INVESTMENT FUND                                  Equity Growth Division (142)                     _____%     _____%
Quality Bond Division (139)                  _____%     _____%    High Yield Division (143)                        _____%     _____%
Small Cap Division (140)                     _____%     _____%
                                                                  VALIC COMPANY I
FIDELITY TEMPLETON VARIABLE INSURANCE                             International Equities Division (132)            _____%     _____%
PRODUCTS FUND                                                     Mid Cap Index Division (133)                     _____%     _____%
VIP Asset Manager Division (159)             _____%     _____%    Money Market I Division (134)                    _____%     _____%
VIP Contrafund Division (158)                _____%     _____%    Nasdaq-100 Index Division (136)                  _____%     _____%
VIP Equity-Income Division (156)             _____%     _____%    Science & Technology Division (137)              _____%     _____%
VIP Growth Division (157)                    _____%     _____%    Small Cap Index Division (138)                   _____%     _____%
                                                                  Stock Index Division (135)                       _____%     _____%
FRANKLIN TEMPLETON VARIABLE INSURANCE PRODUCTS TRUST
Franklin U.S. Government Division (174)      _____%     _____%    VANGUARD VARIABLE INSURANCE FUND
Mutual Shares Securities Division (175)      _____%     _____%    High Yield Bond Division (171)                   _____%     _____%
Templeton International Securities                                REIT Index Division (172)                        _____%     _____%
 Division (176)                              _____%     _____%
                                                                  VAN KAMPEN LIFE INVESTMENT TRUST
JANUS ASPEN SERIES                                                Strategic Stock Division (149)                   _____%     _____%
Aggressive Growth Division (162)             _____%     _____%
International Growth Division (160)          _____%     _____%    OTHER:_____________________________              _____%     _____%
Worldwide Growth Division (161)              _____%     _____%                                                      100%       100%

J.P. MORGAN SERIES TRUST II
J.P. Morgan Small Company Division (163)     _____%     _____%

MFS VARIABLE INSURANCE TRUST
MFS Capital Opportunities Division (165)     _____%     _____%
MFS Emerging Growth Division (141)           _____%     _____%
MFS New Discovery Division (166)             _____%     _____%
MFS Research Division (164)                  _____%     _____%
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AGLC 0461-2001                                                                                                          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 Equity Division (130)  $__________       Mid-Cap Growth Division (167)                       $__________
AIM V.I. Value Division (131)                 $__________
                                                                PIMCO VARIABLE INSURANCE TRUST
AMERICAN CENTURY VARIABLE PORTFOLIOS, INC.                      PIMCO Real Return Bond Division (169)               $__________
VP Value Division (153)                       $__________       PIMCO Short-Term Bond Division (168)                $__________
                                                                PIMCO Total Return Bond Division (170)              $__________
AYCO SERIES TRUST
Ayco Growth Division (154)                    $__________       PUTNAM VARIABLE TRUST
                                                                Putnam VT Diversified Income Division (144)         $__________
CREDIT SUISSE WARBURG PINCUS TRUST                              Putnam VT Growth and Income Division (145)          $__________
Small Company Growth Division (173)           $__________       Putnam VT Int'l Growth and Income Division (146)    $__________

DREYFUS INVESTMENT PORTFOLIOS                                   SAFECO RESOURCE SERIES TRUST
MidCap Stock Division (155)                   $__________       Equity Division (147)                               $__________
                                                                Growth Opportunities Division (148)                 $__________
DREYFUS VARIABLE INVESTMENT FUND
Quality Bond Division (139)                   $__________       THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
Small Cap Division (140)                      $__________       Equity Growth Division (142)                        $__________
                                                                High Yield Division (143)                           $__________
FIDELITY VARIABLE INSURANCE PRODUCTS FUND
VIP Asset Manager Division (159)              $__________       VALIC COMPANY I
VIP Contrafund Division (158)                 $__________       International Equities Division (132)               $__________
VIP Equity-Income Division (156)              $__________       Mid Cap Index Division (133)                        $__________
VIP Growth Division (157)                     $__________       Nasdaq-100 Index Division (136)                     $__________
                                                                Science & Technology Division (137)                 $__________
FRANKLIN TEMPLETON VARIABLE INSURANCE PRODUCTS TRUST            Small Cap Index Division (138)                      $__________
Franklin U.S. Government Division (174)       $__________       Stock Index Division (135)                          $__________
Mutual Shares Securities Division (175)       $__________
Templeton International Securities                              VANGUARD VARIABLE INSURANCE FUND
 Division (176)                               $__________       High Yield Bond Division (171)                      $__________
                                                                REIT Index Division (172)                           $__________
JANUS ASPEN SERIES
Aggressive Growth Division (162)              $__________       VAN KAMPEN LIFE INVESTMENT TRUST
International Growth Division (160)           $__________       Strategic Stock Division (149)                      $__________
Worldwide Growth Division (161)               $__________
                                                                OTHER: _______________________________              $__________
J.P. MORGAN SERIES TRUST II
J.P Morgan Small Company Division (163)       $__________

MFS VARIABLE INSURANCE TRUST
MFS Capital Opportunities Division (165)      $__________
MFS Emerging Growth Division (141)            $__________
MFS New Discovery Division (166)              $__________
MFS Research Division (164)                   $__________
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Automatic Rebalancing
------------------------------------------------------------------------------------------------------------------------------------
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
------------------------------------------------------------------------------------------------------------------------------------
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 0461-2001                                                                                                           Page 2 of 4
</TABLE>

<PAGE>

<TABLE>
<CAPTION>
<S>                                                    <C>                                                       <C>
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Death Benefit Compliance Test
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                           [_] Guideline Premium Test                           [_] Cash Value Accumulation Test
------------------------------------------------------------------------------------------------------------------------------------
Specified Amount
------------------------------------------------------------------------------------------------------------------------------------
Base Coverage $______________________plus Supplemental Coverage $ _________________________ = Total Specified Amount $ _____________

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Telephone Authorization
------------------------------------------------------------------------------------------------------------------------------------
                      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.
------------------------------------------------------------------------------------------------------------------------------------
Suitability
------------------------------------------------------------------------------------------------------------------------------------
All questions must    1. Have you, the Proposed Insured(s) or Owner(s) (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 0461-2001                                                                                                           Page 3 of 4
</TABLE>

<PAGE>

<TABLE>
<CAPTION>
<S>                                  <C>                                                                <C>
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Acknowledgements
------------------------------------------------------------------------------------------------------------------------------------
             The following states require the applicants to acknowledge the information below that pertains to their specific State.
             Check the appropriate box for your application state, and sign and date the Your Signature section below.

             [ ] FLORIDA
                 Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an
                 application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

             [ ] MAINE
                 It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
                 purpose of defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefit.

             [ ] NEW MEXICO
                 Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
                 presents false information in an application for insurance is guilty of a crime and may be subject to civil fines
                 and criminal penalties.
------------------------------------------------------------------------------------------------------------------------------------
Your Signature
------------------------------------------------------------------------------------------------------------------------------------

Signatures   Signed at (city, state)
             -----------------------------------------------------------------------------------------------------------------------

             Print name of Broker/Dealer
             -----------------------------------------------------------------------------------------------------------------------

             X Registered Representative                                      State license #                   Date
             -----------------------------------------------------------------------------------------------------------------------

             X Proposed Contingent Insured                                                                      Date
             ----------------------------------------------------------------------------------------------------------------------

             X Other Proposed Contingent Insured                                                                Date
             ----------------------------------------------------------------------------------------------------------------------

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

             X Additional Owner                                                                                 Date
             ----------------------------------------------------------------------------------------------------------------------
             (If different from Other Proposed Contingent Insured)
-----------------------------------------------------------------------------------------------------------------------------------
AGLC 0461-2001                                                                                                          Page 4 of 4
</TABLE>

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