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                                                                 EXHIBIT (10)(d)
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                   JOINT AND LAST SURVIVOR                                                                       AMERICAN
                   VARIABLE UNIVERSAL LIFE INSURANCE                                                                |GENERAL
                   SUPPLEMENTAL APPLICATION                                                                         |FINANCIAL GROUP

                   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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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 (36)                     _____%     ____%
AIM VARIABLE INSURANCE FUNDS
AIM V.I. International Growth Division (1)  _____%     _____%     PIMCO VARIABLE INSURANCE TRUST
AIM V.I. Premier Equity Division (2)        _____%     _____%     PIMCO Real Return Division (101)                 _____%     _____%
                                                                  PIMCO Short-Term Division (37)                   _____%     _____%
AMERICAN CENTURY VARIABLE PORTFOLIOS, INC.                        PIMCO Total Return Division (102)                _____%     _____%
VP Value Division (19)                      _____%     _____%
                                                                  PUTNAM VARIABLE TRUST
AYCO SERIES TRUST                                                 Putnam VT Diversified Income Division (12)       _____%     _____%
Ayco Growth Division (23)                   _____%     _____%     Putnam VT Growth and Income Division (13)        _____%     _____%
                                                                  Putnam VT Int'I Growth and Income Division (14)  _____%     _____%
CREDIT SUISSE TRUST
Small Cap Growth Division (105)             _____%     _____%     SAFECO RESOURCE SERIES TRUST
                                                                  Equity Division (15)                             _____%     _____%
DREYFUS INVESTMENT PORTFOLIOS                                     Growth Opportunities Division (16)               _____%     _____%
MidCap Stock Division (24)                  _____%     _____%
                                                                  SUNAMERICA SERIES TRUST
DREYFUS VARIABLE INVESTMENT FUND                                  SunAmerica Balanced Division (110)               _____%     _____%
Quality Bond Division (7)                   _____%     _____%     Aggressive Growth Division (111)                 _____%     _____%
Small Cap Division (8)                      _____%     _____%
                                                                  THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
FIDELITY VARIABLE INSURANCE PRODUCTS FUND                         Equity Growth Division (10)                      _____%     _____%
VIP Asset Manager Division (28)             _____%     _____%     High Yield Division (11)                         _____%     _____%
VIP Contrafund Division (27)                _____%     _____%
VIP Equity-Income Division (25)             _____%     _____%     VALIC COMPANY I
VIP Growth Division (26)                    _____%     _____%     International Equities Division (3)              _____%     _____%
                                                                  Mid Cap Index Division (4)                       _____%     _____%
FRANKLIN TEMPLETON VARIABLE INSURANCE PRODUCTS TRUST              Money Market I Division (5)                      _____%     _____%
Franklin U.S. Government Division (106)     _____%     _____%     Nasdaq-100 Index Division (20)                   _____%     _____%
Mutual Shares Securities Division (107)     _____%     _____%     Science & Technology Division (21)               _____%     _____%
Templeton Foreign Securities Division (108) _____%     _____%     Small Cap Index Division (22)                    _____%     _____%
                                                                  Stock Index Division (6)                         _____%     _____%
JANUS ASPEN SERIES
Aggressive Growth Division (31)             _____%     _____%     VANGUARD VARIABLE INSURANCE FUND
International Growth Division (29)          _____%     _____%     High Yield Bond Division (103)                   _____%     _____%
Worldwide Growth Division (30)              _____%     _____%     REIT Index Division (104)                        _____%     _____%

J.P. MORGAN SERIES TRUST II                                       VAN KAMPEN LIFE INVESTMENT TRUST
JPMorgan Small Company Division (32)        _____%     _____%     Growth & Income Division (109)                   _____%     _____%

MFS VARIABLE INSURANCE TRUST                                      OTHER:_____________________________              _____%     _____%
MFS Capital Opportunities Division (34)     _____%     _____%                                                       100%       100%
MFS Emerging Growth Division(9)             _____%     _____%
MFS New Discovery Division (35)             _____%     _____%
MFS Research Division (33)                  _____%     _____%
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AGLC 0093-99 REV 0800                                                                                                   Page  1 of 4
                                                                                                                                0502
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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 (1)   $__________         Mid-Cap Growth Division (36)                        $__________
AIM V.I. Premier Equity Division (2)         $__________
                                                                 PIMCO VARIABLE INSURANCE TRUST
AMERICAN CENTURY VARIABLE PORTFOLIOS, INC.                       PIMCO Real Return Division (101)                    $__________
VP Value Division (19)                       $__________         PIMCO Short-Term Division (37)                      $__________
                                                                 PIMCO Total Return Division (102)                   $__________
AYCO SERIES TRUST
Ayco Growth Division (23)                    $__________         PUTNAM VARIABLE TRUST
                                                                 Putnam VT Diversified Income Division (12)          $__________
CREDIT SUISSE TRUST                                              Putnam VT Growth and Income Division (13)           $__________
Small Cap Growth Division (105)              $__________         Putnam VT Int'I Growth and Income Division (14)     $__________

DREYFUS INVESTMENT PORTFOLIOS                                    SAFECO RESOURCE SERIES TRUST
MidCap Stock Division (24)                   $__________         Equity Division (15)                                $__________
                                                                 Growth Opportunities Division (16)                  $__________
DREYFUS VARIABLE INVESTMENT FUND
Quality Bond Division (7)                    $__________         SUNAMERICA SERIES TRUST
Small Cap Division (8)                       $__________         SunAmerica Balanced Division (110)                  $__________
                                                                 Aggressive Growth Division (111)                    $__________
FIDELITY VARIABLE INSURANCE PRODUCTS FUND
VIP Asset Manager Division (28)              $__________         THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
VIP Contrafund Division (27)                 $__________         Equity Growth Division (10)                         $__________
VIP Equity-Income Division (25)              $__________         High Yield Division (11)                            $__________
VIP Growth Division (26)                     $__________
                                                                 VALIC COMPANY I
FRANKLIN TEMPLETON VARIABLE INSURANCE PRODUCTS TRUST             International Equities Division (3)                 $__________
Franklin U.S. Government Division (106)      $__________         Mid Cap Index Division (4)                          $__________
Mutual Shares Securities Division (107)      $__________         Nasdaq-100 Index Division (20)                      $__________
Templeton Foreign Securities Division (108)  $__________         Science & Technology Division (21)                  $__________
                                                                 Small Cap Index Division (22)                       $__________
JANUS ASPEN SERIES                                               Stock Index Division (6)                            $__________
Aggressive Growth Division (31)              $__________
International Growth Division (29)           $__________         VANGUARD VARIABLE INSURANCE FUND
Worldwide Growth Division (30)               $__________         High Yield Bond Division (103)                      $__________
                                                                 REIT Index Division (104)                           $__________
J.P. MORGAN SERIES TRUST II
JPMorgan Small Company Division (32)         $__________         VAN KAMPEN LIFE INVESTMENT TRUST
                                                                 Growth & Income Division (109)                      $__________
MFS VARIABLE INSURANCE TRUST
MFS Capital Opportunities Division (34)      $__________         OTHER _______________________________               $__________
MFS Emerging Growth Division (9)             $__________
MFS New Discovery Division (35)              $__________
MFS Research Division (33)                   $__________
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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 0093-99 REV 0800                                                                                                    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. In 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(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 0093-99 REV 0800                                                                                                    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 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 Proposed Contingent Insured)
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AGLC 0093-99 REV 0800                                                                                                    Page 4 of 4
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----------------------------------
|                SERVICE REQUEST |
----------------------------------

                                                                 EXHIBIT (10)(E)

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     P   L   A   T   I   N   U   M
----------------------------------
             INVESTOR/SM/ SURVIVOR
----------------------------------
             AMERICAN GENERAL LIFE
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PLATINUM INVESTOR--FIXED DIVISION
     .  Division 18 - AGL Declared Fixed Interest Account

PLATINUM INVESTOR SURVIVOR--VARIABLE DIVISIONS

AIM Variable Insurance Funds                                        Neuberger Berman Advisers Management Trust
----------------------------                                        ------------------------------------------
     .  Division 1 - AIM V.I. International Growth                       .  Division 36 - Mid-Cap Growth
     .  Division 2 - AIM V.I. Premier Equity
                                                                    PIMCO Variable Insurance Trust
American Century Variable Portfolios, Inc.                          ------------------------------
------------------------------------------                               .  Division 101 - PIMCO Real Return
     .  Division 19 - VP Value                                           .  Division 37 - PIMCO Short-Term
                                                                         .  Division 102 - PIMCO Total Return
Ayco Series Trust
-----------------                                                   Putnam Variable Trust
     .  Division 23 - Ayco Growth                                   ---------------------
                                                                         .  Division 12 - Putnam VT Diversified Income
Credit Suisse Trust                                                      .  Division 13 - Putnam VT Growth and Income
-------------------                                                      .  Division 14 - Putnam VT Int'l Growth and Income
     . Division 105 - Small Cap Growth
                                                                    SAFECO Resource Series Trust
Dreyfus Investment Portfolios                                       ----------------------------
-----------------------------                                            .  Division 15 - Equity
     .  Division 24 - MidCap Stock                                       .  Division 16 - Growth Opportunities

Dreyfus Variable Investment Fund                                    SunAmerica Series Trust
--------------------------------                                    -----------------------
     .  Division 7 - Quality Bond                                        . Division 111 - Aggressive Growth
     .  Division 8 - Small Cap                                           . Division 110 - SunAmerica Balanced

Fidelity Variable Insurance Products Fund                           The Universal Institutional Funds, Inc.
-----------------------------------------                           ---------------------------------------
     .  Division 28 - VIP Asset Manager                                  .  Division 10 - Equity Growth
     .  Division 27 - VIP Contrafund                                     .  Division 11 - High Yield
     .  Division 25 - VIP Equity-Income
     .  Division 26 - VIP Growth                                    VALIC Company I
                                                                    ---------------
Franklin Templeton Variable Insurance Products Trust                     . Division 3 - International Equities
----------------------------------------------------                     . Division 4 - Mid Cap Index
     . Division 106 - Franklin U.S. Government                           . Division 5 - Money Market I
     . Division 107 - Mutual Shares Securities                           . Division 20 - Nasdaq-100 Index
     . Division 108 - Templeton Foreign Securities                       . Division 21 - Science & Technology
                                                                         . Division 22 - Small Cap Index
Janus Aspen Series                                                       . Division 6 - Stock Index
------------------
     .  Division 31 - Aggressive Growth                             Vanguard Variable Insurance Fund
     .  Division 29 - International Growth                          --------------------------------
     .  Division 30 - Worldwide Growth                                   .  Division 103 - High Yield Bond
                                                                         .  Division 104 - REIT Index
J.P. Morgan Series Trust II
---------------------------                                         Van Kampen Life Investment Trust
     .  Division 32 - JPMorgan Small Company                        --------------------------------
                                                                         .  Division 17 - Growth & Income
MFS Variable Insurance Trust
----------------------------
     .  Division 34 - MFS Capital Opportunities
     .  Division 9 - MFS Emerging Growth
     .  Division 35 - MFS New Discovery
     .  Division 33 - MFS Research
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AGLC0094 Rev0302
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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 #:________________________   CONTINGENT INSURED:_________________________________________
       IDENTIFICATION             |                                     CONTINGENT INSURED:_________________________________________
                                  | ADDRESS:________________________________________________________________ New Address (yes) (no)
    COMPLETE THIS SECTION FOR     | Primary Owner (if other than an insured):_______________________________
         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)    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  | Reason for Change: (Circle One) Marriage Divorce Correction Other (Attach copy of legal proof)
 note, this does 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                       _____ _____  (36) Mid-Cap Growth              ______  ______
  Use this section to indicate    |
     how premiums or monthly      | AIM VARIABLE INSURANCE FUNDS                     PIMCO VARIABLE INSURANCE TRUST
 deductions are to be allocated.  | (1)  AIM V.I. International Growth  _____ _____  (101) PIMCO Real Return          ______  ______
 Total allocation in each column  | (2)  AIM V.I. Premier Equity        _____ _____  (37)  PIMCO Short-Term           ______  ______
     must equal 100%; whole       |                                                  (102) PIMCO Total Return         ______  ______
         numbers only.            | AMERICAN CENTURY VARIABLE PORTFOLIOS, INC.
                                  | (19) VP Value                       _____ _____  PUTNAM VARIABLE TRUST
                                  |                                                  (12) Putnam VT Diversified Income______  ______
                                  | AYCO SERIES TRUST                                (13) Putnam VT Growth and Income ______  ______
                                  | (23) Ayco Growth                    _____ _____  (14) Putnam VT Int'l Growth and
                                  |                                                       Income                      ______  ______
                                  | CREDIT SUISSE TRUST
                                  | (105) Small Cap Growth              _____ _____  SAFECO RESOURCE SERIES TRUST
                                  |                                                  (15) Equity                      ______  ______
                                  | DREYFUS INVESTMENT PORTFOLIOS                    (16) Growth Opportunities        ______  ______
                                  | (24) MidCap Stock                   _____ _____
                                  |                                                  SUNAMERICA SERIES TRUST
                                    DREYFUS VARIABLE INVESTMENT FUND                 (111) Aggressive Growth          ______  ______
                                  | (7) Quality Bond                    _____ _____  (110) SunAmerica Balanced        ______  ______
                                  | (8) Small Cap                       _____ _____
                                  |                                                  THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
                                  | FIDELITY VARIABLE INSURANCE PRODUCTS FUND        (10) Equity Growth               ______  ______
                                  | (28) VIP Asset Manager              _____ _____  (11) High Yield                  ______  ______
                                  | (27) VIP Contrafund                 _____ _____
                                  | (25) VIP Equity-Income              _____ _____  VALIC COMPANY I
                                  | (26) VIP Growth                     _____ _____  (3)  International Equities      ______  ______
                                  |                                                  (4)  Mid Cap Index               ______  ______
                                  | FRANKLIN TEMPLETON VARIABLE INSURANCE            (5)  Money Market I              ______  ______
                                  | PRODUCTS TRUST                                   (20) Nasdaq-100 Index            ______  ______
                                  | (106) Franklin U.S. Government      _____ _____  (21) Science and Technology      ______  ______
                                  | (107) Mutual Shares Securities      _____ _____  (22) Small Cap Index             ______  ______
                                  | (108) Templeton Foreign Securities  _____ _____  (6)  Stock Index                 ______  ______
                                  |
                                  | JANUS ASPEN SERIES                               VANGUARD VARIABLE INSURANCE FUND
                                  | (31) Aggressive Growth              _____ _____  (103) High Yield Bond            ______  ______
                                  | (29) International Growth           _____ _____  (104) REIT Index                 ______  ______
                                  | (30) Worldwide Growth               _____ _____
                                  |                                                  VAN KAMPEN LIFE INVESTMENT TRUST
                                  | J.P. MORGAN SERIES TRUST II                      (17) Growth & Income             ______  ______
                                  | (32) JPMorgan Small Company         _____ _____
                                  |                                                  OTHER:_______________________    ______  ______
                                  | MFS VARIABLE INSURANCE TRUST                                                       100%    100%
                                  | (34) MFS Capital Opportunities      _____ _____
                                  | (9)  MFS Emerging Growth            _____ _____
                                  | (35) MFS New Discovery              _____ _____
                                  | (33) MFS Research                   _____ _____
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AGLC0094 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, 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    | AIM VARIABLE INSURANCE FUNDS                    NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST
 placed in one or more of the     | (1) AIM V.I. International Growth     $_______  (36) Mid-Cap Growth                     $_______
        Divisions listed.         | (2) AIM V.I. Premier Equity           $_______
     The AGL Declared Fixed       |                                                 PIMCO VARIABLE INSURANCE TRUST
Interest Account is not available | AMERICAN CENTURY VARIABLE PORTFOLIOS, INC.      (101) PIMCO Real Return                 $_______
    for Dollar Cost Averaging.    | (19) VP Value                         $_______  (37)  PIMCO Short-Term                  $_______
 Please refer to the prospectus   |                                                 (102) PIMCO Total Return                $_______
   for more information on the    | AYCO SERIES TRUST
  Dollar Cost Averaging Option.   | (23) Ayco Growth                      $_______  PUTNAM VARIABLE TRUST
        Averaging Option.         |                                                 (12) Putnam VT Diversified Income       $_______
Note: Automatic Rebalancing is    | CREDIT SUISSE TRUST                             (13) Putnam VT Growth and Income        $_______
not available if the Dollar Cost  | (105) Small Cap Growth                $_______  (14) Putnam VT Int'l Growth and Income  $_______
  Averaging Option is chosen.     |
                                  | DREYFUS INVESTMENT PORTFOLIOS                    SAFECO RESOURCE SERIES TRUST
                                  | (24) MidCap Stock                     $_______   (15) Equity                            $_______
                                  |                                                  (16) Growth Opportunities              $_______
                                  | DREYFUS VARIABLE INVESTMENT FUND
                                  | (7) Quality Bond                      $_______   SUNAMERICA SERIES TRUST
                                  | (8) Small Cap                         $_______   (111) Aggressive Growth                $_______
                                  |                                                  (110) SunAmerica Balanced              $_______
                                  | FIDELITY VARIABLE INSURANCE PRODUCTS FUND
                                  | (28) VIP Asset Manager                $_______   THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
                                  | (27) VIP Contrafund                   $_______   (10) Equity Growth                     $_______
                                  | (25) VIP Equity-Income                $_______   (11) High Yield                        $_______
                                  | (26) VIP Growth                       $_______
                                  |                                                  VALIC Company I
                                  | FRANKLIN TEMPLETON VARIABLE INSURANCE            (3)  International Equities            $_______
                                  | PRODUCTS TRUST                                   (4)  Mid Cap Index                     $_______
                                  | (106) Franklin U.S. Government        $_______   (20) Nasdaq-100 Index                  $_______
                                  | (107) Mutual Shares Securities        $_______   (21) Science & Technology              $_______
                                  | (108) Templeton Foreign Securities    $_______   (22) Small Cap Index                   $_______
                                  |                                                  (6)  Stock Index                       $_______
                                  | JANUS ASPEN SERIES
                                  | (31) Aggressive Growth                $_______   VANGUARD VARIABLE INSURANCE FUND
                                  | (29) International Growth             $_______   (103) High Yield Bond                  $_______
                                  | (30) Worldwide Growth                 $_______   (104) REIT Index                       $_______
                                  |
                                  | J.P. MORGAN SERIES TRUST II                      VAN KAMPEN LIFE INVESTMENT TRUST
                                  | (32) JPMorgan Small Company           $_______   (17) Growth & Income                   $_______
                                  |
                                  | MFS VARIABLE INSURANCE TRUST                     OTHER:_____________________________    $_______
                                  | (34) MFS Capital Opportunities        $_______
                                  | (9)  MFS Emerging Growth              $_______
                                  | (35) MFS New Discovery                $_______
                                  | (33) MFS Research                     $_______
                                  | ______ INITIAL HERE TO REVOKE DOLLAR COST AVERAGING ELECTION.
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AGLC0094 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 Options 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
       PRIVILEGE                  | values among the Variable Divisions and Declared Fixed Interest Account and to change
       AUTHORIZATION              | allocations for future purchase payments and monthly deductions.
                                  |
 Complete this section if you     | Initial the designation you prefer:
 are applying for or revoking     |
 current 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             | Transfer $_______ or _______% from ____________________________ to _____________________________
     Withdrawals from the AGL     |
 Declared Fixed Interest Account  | Transfer $_______ or _______% from ____________________________ to _____________________________
   to a Variable Division may     |
  only be made within the 60 days | Transfer $_______ or _______% from ____________________________ to _____________________________
   after a contract anniversary.  |
See transfer limitations outlined | Transfer $_______ or _______% from ____________________________ to _____________________________
   in prospectus. If a transfer   |
    causes the balance in any     | Transfer $_______ or _______% from ____________________________ to _____________________________
division to drop below $500, AGL  |
 reserves the right to transfer   | Transfer $_______ or _______% from ____________________________ to _____________________________
 the remaining balance. Amounts   |
  to be transferred should be     | Transfer $_______ or _______% from ____________________________ to _____________________________
indicated in dollar or percentage |
     amounts, maintaining         | Transfer $_______ or _______% from ____________________________ to _____________________________
    consistency throughout.       |
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AGLC0094 Rev0302                                                    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.
                                  |
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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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AGLC0094 Rev0302                                               PAGE 5 OF 5
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