Document:

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                                                                 EXHIBIT (10)(d)

                                                              AMERICAN
                                                                |GENERAL
                                                                |FINANCIAL GROUP
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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>

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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 Equity Division (1)  _____%     _____%     PIMCO VARIABLE INSURANCE TRUST
AIM V.I. Value Division (2)                 _____%     _____%     PIMCO Real Return Bond Division (101)            _____%     _____%
                                                                  PIMCO Short-Term Bond Division (37)              _____%     _____%
AMERICAN CENTURY VARIABLE PORTFOLIOS, INC.                        PIMCO Total Return Bond 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'l Growth and Income Division (14)  _____%     _____%
CREDIT SUISSE WARBURG PINCUS TRUST
Small Company Growth Division (105)         _____%     _____%     SAFECO RESOURCE SERIES TRUST
                                                                  Equity Division (15)                             _____%     _____%
DREYFUS INVESTMENT PORTFOLIOS                                     Growth Opportunities Division (16)               _____%     _____%
MidCap Stock Division (24)                  _____%     _____%
                                                                  THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
DREYFUS VARIABLE INVESTMENT FUND                                  Equity Growth Division (10)                      _____%     _____%
Quality Bond Division (7)                   _____%     _____%     High Yield Division (11)                         _____%     _____%
Small Cap Division (8)                      _____%     _____%
                                                                  VALIC COMPANY I
FIDELITY VARIABLE INSURANCE PRODUCTS FUND                         International Equities Division (3)              _____%     _____%
VIP Asset Manager Division (28)             _____%     _____%     Mid Cap Index Division (4)                       _____%     _____%
VIP Contrafund Division (27)                _____%     _____%     Money Market I Division (5)                      _____%     _____%
VIP Equity-Income Division (25)             _____%     _____%     Nasdaq-100 Index Division (20)                   _____%     _____%
VIP Growth Division (26)                    _____%     _____%     Science & Technology Division (21)               _____%     _____%
                                                                  Small Cap Index Division (22)                    _____%     _____%
FRANKLIN TEMPLETON VARIABLE INSURANCE PRODUCTS TRUST              Stock Index Division (6)                         _____%     _____%
Franklin U.S. Government Division (106)     _____%     _____%
Mutual Shares Securities Division (107)     _____%     _____%     VANGUARD VARIABLE INSURANCE FUND
Templeton International Securities                                High Yield Bond Division (103)                   _____%     _____%
 Division(108)                              _____%     _____%     REIT Index Division (104)                        _____%     _____%

JANUS ASPEN SERIES                                                VAN KAMPEN LIFE INVESTMENT TRUST
Aggressive Growth Division (31)             _____%     _____%     Strategic Stock Division (17)                    _____%     _____%
International Growth Division (29)          _____%     _____%
Worldwide Growth Division (30)              _____%     _____%     OTHER:_____________________________              _____%     _____%
                                                                                                                    100%       100%
J.P. MORGAN SERIES TRUST II
J.P. Morgan Small Company Division (32)     _____%     _____%

MFS VARIABLE INSURANCE TRUST
MFS Capital Opportunities Division (34)     _____%     _____%
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
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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 (1)  $__________         Mid-Cap Growth Division (36)                        $__________
AIM V.I. Value Division (2)                 $__________
                                                                PIMCO VARIABLE INSURANCE TRUST
AMERICAN CENTURY VARIABLE PORTFOLIOS, INC.                      PIMCO Real Return Bond Division (101)               $__________
VP Value Division (19)                      $__________         PIMCO Short-Term Bond Division (37)                 $__________
                                                                PIMCO Total Return Bond Division (102)              $__________
AYCO SERIES TRUST
Ayco Growth Division (23)                   $__________         PUTNAM VARIABLE TRUST
                                                                Putnam VT Diversified Income Division (12)          $__________
CREDIT SUISSE WARBURG PINCUS TRUST                              Putnam VT Growth and Income Division (13)           $__________
Small Company Growth Division (105)         $__________         Putnam VT Int'l 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)                   $__________         THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
Small Cap Division (8)                      $__________         Equity Growth Division (10)                         $__________
                                                                High Yield Division (11)                            $__________
FIDELITY VARIABLE INSURANCE PRODUCTS FUND
VIP Asset Manager Division (28)             $__________         VALIC COMPANY I
VIP Contrafund Division (27)                $__________         International Equities Division (3)                 $__________
VIP Equity-Income Division (25)             $__________         Mid Cap Index Division (4)                          $__________
VIP Growth Division (26)                    $__________         Nasdaq-100 Index Division (20)                      $__________
                                                                Science & Technology Division (21)                  $__________
FRANKLIN TEMPLETON VARIABLE INSURANCE PRODUCTS TRUST            Small Cap Index Division (22)                       $__________
Franklin U.S. Government Division (106)     $__________         Stock Index Division (6)                            $__________
Mutual Shares Securities Division (107)     $__________
Templeton International Securities                              VANGUARD VARIABLE INSURANCE FUND
 Division (108)                             $__________         High Yield Bond Division (103)                      $__________
                                                                REIT Index Division (104)                           $__________
JANUS ASPEN SERIES
Aggressive Growth Division (31)             $__________         VAN KAMPEN LIFE INVESTMENT TRUST
International Growth Division (29)          $__________         Strategic Stock Division (17)                       $__________
Worldwide Growth Division (30)              $__________
                                                                OTHER: ______________________________               $__________
J.P. MORGAN SERIES TRUST II
J.P Morgan Small Company Division (32)      $__________

MFS VARIABLE INSURANCE TRUST
MFS Capital Opportunities Division (34)     $__________
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. I understand that this
                      authorization is subject to the terms and provisions of my variable universal life insurance policy and its
                      related prospectus. This authorization will remain in effect until my written notice of its revocation is
                      received by AGL at its home office.
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Suitability
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ALL QUESTIONS MUST    1. Have you, the Proposed Insured(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
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             X Proposed Contingent Insured                                                                      Date
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             X Other Proposed Contingent Insured                                                                Date
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             X Owner                                                                                            Date
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             (If different from Proposed Contingent Insured)

             X Additional Owner                                                                                 Date
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             (If different from Proposed Contingent Insured)
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AGLC 0093-99 REV 0800                                                                                                   Page 4 of 4
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                                                                 EXHIBIT (10)(e)

            SERVICE REQUEST

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

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PLATINUM INVESTOR SURVIVOR--FIXED OPTION

 . 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 Equity                    . Division 36 - Mid-Cap Growth

 . Division 2 - AIM V.I. Value                                   PIMCO Variable Insurance Trust
                                                                ------------------------------
American Century Variable Portfolios, Inc.
------------------------------------------                      . Division 101 - PIMCO Real Return Bond

 . Division 19 - VP Value                                        . Division 37 - PIMCO Short-Term Bond

Ayco Series Trust                                               . Division 102 - PIMCO Total Return Bond
-----------------
                                                                Putnam Variable Trust
 . Division 29 - Ayco Growth                                     ---------------------

Credit Suisse Warburg Pincus Trust                              . Division 12 - Putnam VT Diversified Income
----------------------------------
                                                                . Division 13 - Putnam VT Growth and Income
 . Division 105 - Small Company Growth
                                                                . Division 14 - Putnam VT Int'l Growth and Income
Dreyfus Investment Portfolios
-----------------------------                                   SAFECO Resource Series Trust
                                                                ----------------------------
 . Division 24 - MidCap Stock
                                                                . Division 15 - Equity
Dreyfus Variable Investment Fund
--------------------------------                                . Division 16 - Growth Opportunities

 . Division 7 - Quality Bond                                     The Universal Institutional Funds, Inc.
                                                                ---------------------------------------
 . Division 8 - Small Cap
                                                                . Division 10 - Equity Growth
Fidelity Variable Insurance Products Fund
-----------------------------------------                       . Division 11 - High Yield

 . Division 28 - VIP Asset Manager                               VALIC Company I
                                                                ---------------
 . Division 27 - VIP Contrafund
                                                                . Division 3 - International Equities
 . Division 25 - VIP Equity-Income
                                                                . Division 4 - Mid Cap Index
 . Division 26 - VIP Growth
                                                                . Division 5 - Money Market I
Franklin Templeton Variable Insurance Products Trust
----------------------------------------------------            . Division 20 - Nasdaq-100 Index

 . Division 106 - Franklin U.S. Government                       . Division 21 - Science & Technology

 . Division 107 - Mutual Shares Securities                       . Division 22 - Small Cap Index

 . Division 108 - Templeton International Securities             . Division 6 - Stock Index

Janus Aspen Series                                              Vanguard Variable Insurance Fund
------------------                                              -------------------------------

 . Division 31 - Aggressive Growth                               . Division 103 - High Yield Bond

 . Division 29 - International Growth                            . Division 104 - REIT Index

 . Division 30 - Worldwide Growth                                Van Kampen Life Investment Trust
                                                                --------------------------------
J.P. Morgan Series Trust II
---------------------------                                     . Division 17 - Strategic Stock

 . Division 32 - J.P. Morgan Small Company

MFS Variable Insurance Trust
----------------------------

 . Division 34 - MFS Capital Opportunities

 . Division 9 - MFS Emerging Growth

 . Division 35 - MFS New Discovery

 . Division 33 - MFS Research

AGLC0094 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

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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 note, this does  | __________________________________________________    _________________________________________
   not change the Contingent      |
    Insureds, Owner, Payor or     | Reason for Change: (Circle One) Marriage Divorce Correction Other (Attach copy of legal proof)
    Beneficiary designation.)     |
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  [_]  CHANGE IN               3. | INVESTMENT DIVISION                 PREM % DED % INVESTMENT DIVISION                PREM % DED %
       ALLOCATION                 | (18) AGL DECLARED FIXED INTEREST                 MFS VARIABLE INSURANCE TRUST
       PERCENTAGES                |      ACCOUNT                        _____ _____  (34) MFS Capital Opportunities     _____  _____
  Use this section to indicate    | AIM VARIABLE INSURANCE FUNDS                     (9) MFS Emerging Growth            _____  _____
     how premiums or monthly      | (1) AIM V.I. International Equity   _____ _____  (35) MFS New Discovery             _____  _____
 deductions are to be allocated.  | (2) AIM V.I. Value                  _____ _____  (33) MFS Research                  _____  _____
 Total allocation in each column  |
     must equal 100%; whole       | AMERICAN CENTURY VARIABLE PORTFOLIOS, INC.       NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST
         numbers only.            | (19) VP Value                       _____ _____  (36) Mid-Cap Growth                _____  _____
                                  |
                                  | AYCO SERIES TRUST                                PIMCO VARIABLE INSURANCE TRUST
                                  | (23) Ayco Growth                    _____ _____  (101) PIMCO Real Return Bond       _____  _____
                                  |                                                  (37)  PIMCO Short-Term Bond        _____  _____
                                  | CREDIT SUISSE WARBURG PINCUS TRUST               (102) PIMCO Total Return Bond      _____  _____
                                  | (105) Small Company Growth          _____ _____
                                  |                                                  PUTNAM VARIABLE TRUST
                                  | DREYFUS INVESTMENT PORTFOLIOS                    (12) Putnam VT Diversified Income  _____  _____
                                  | (24) Midcap Stock                   _____ _____  (13) Putnam VT Growth and Income   _____  _____
                                  |                                                  (14) Putnam VT Int'l Growth and
                                  | DREYFUS VARIABLE INVESTMENT FUND                        Income                      _____  _____
                                  | (7) Quality Bond                    _____ _____
                                  | (8) Small Cap                       _____ _____  SAFECO RESOURCE SERIES TRUST
                                  |                                                  (15) Equity                        _____  _____
                                  | FIDELITY VARIABLE INSURANCE PRODUCTS FUND        (16) Growth Opportunities          _____  _____
                                  | (28) VIP Asset Manager              _____ _____
                                  | (27) VIP Contrafund                 _____ _____  THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
                                  | (25) VIP Equity-Income              _____ _____  (10) Equity Growth                 _____  _____
                                  | (26) VIP Growth                     _____ _____  (11) High Yield                    _____  _____
                                  |
                                  | FRANKLIN TEMPLETON VARIABLE INSURANCE            VALIC COMPANY I
                                  |  PRODUCTS TRUST                                  (3)  International Equities        _____  _____
                                  | (106) Franklin U.S. Government      _____ _____  (4)  Mid Cap Index                 _____  _____
                                  | (107) Mutual Shares Securities      _____ _____  (5)  Money Market I                _____  _____
                                  | (108) Templeton International       _____ _____  (20) Nasdaq-100 Index              _____  _____
                                  |       Securities                                 (21) Science and Technology        _____  _____
                                  |                                                  (22) Small Cap Index               _____  _____
                                  | JANUS ASPEN SERIES                               (6)  Stock Index                   _____  _____
                                  | (31) Aggressive Growth              _____ _____
                                  | (29) International Growth           _____ _____  VANGUARD VARIABLE INSURANCE FUND
                                  | (30) Worldwide Growth               _____ _____  (103) High Yield Bond              _____  _____
                                  |                                                  (104) REIT Index                   _____  _____
                                  | J.P MORGAN SERIES TRUST II
                                  | (32) J.P Morgan Small Company       _____ _____  VAN KAMPEN LIFE INVESTMENT TRUST
                                  |                                                  (17) Strategic Stock               _____  _____
                                  |
                                  |                                                  OTHER:_______________________      _____  _____
                                  |
                                  |                                                                                      100%   100%
                                  |
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AGLCO094 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| AIM VARIABLE INSURANCE FUNDS                     NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST
  in one or more of the Divisions | (1) AIM V.I. International Equity    $________   (36) Mid-Cap Growth                    $______
 listed. The AGL Declared Fixed   | (2) AIM V.I. Value                   $________
Interest Account is not available |                                                  PIMCO VARIABLE INSURANCE TRUST
for Dollar Cost Averaging. Please | AMERICAN CENTURY VARIABLE PORTFOLIOS, INC.       (101) PIMCO Real Return Bond           $______
refer to the prospectus for more  | (19) VP Value                        $________   (37)  PIMCO Short-Term Bond            $______
 information on the Dollar Cost   |                                                  (102) PIMCO Total Return Bond          $______
Averaging Option. Note: Automatic | AYCO SERIES TRUST
 Rebalancing is not available if  | (23) Ayco Growth                     $________   PUTNAM VARIABLE TRUST
the Dollar Cost Averaging Option  |                                                  (12) Putnam VT Diversified Income      $______
          is chosen.              | CREDIT SUISSE WARBURG PINCUS TRUST               (13) Putnam VT Growth and Income       $______
                                  | (105) Small Company Growth           $________   (14) Putnam VT Int'l Growth and
                                  |                                                       Income                            $______
                                  | DREYFUS INVESTMENT PORTFOLIOS
                                  | (24) MidCap Stock                    $________   SAFECO RESOURCE SERIES TRUST
                                  |                                                  (15) Equity                            $______
                                  |                                                  (16) Growth Opportunities              $______
                                  | DREYFUS VARIABLE INVESTMENT FUND
                                  | (7) Quality Bond                     $________   THE UNIVERSAL INSTITUTIONAL FUNDS, INC.
                                  | (8) Small Cap                        $________   (10) Equity Growth                     $______
                                  |                                                  (11) High Yield                        $______
                                  | FIDELITY VARIABLE INSURANCE PRODUCTS FUND
                                  | (28) VIP Asset Manager               $________   VALIC COMPANY I
                                  | (27) VIP Contrafund                  $________   (3)  International Equities            $______
                                  | (25) VIP Equity-Income               $________   (4)  Mid Cap Index                     $______
                                  | (26) VIP Growth                      $________   (20) Nasdaq-100 Index                  $______
                                  |                                                  (21) Science & Technology              $______
                                  | FRANKLIN TEMPLETON VARIABLE INSURANCE            (22) Small Cap Index                   $______
                                  |  PRODUCTS TRUST                                  (6)  Stock Index                       $______
                                  | (106) Franklin U.S. Government       $________
                                  | (107) Mutual Shares Securities       $________    VANGUARD VARIABLE INSURANCE FUND
                                  | (108) Templeton International                     (103) High Yield Bond                 $______
                                  |       Securities                     $________    (104) REIT Index                      $______
                                  |
                                  | JANUS ASPEN SERIES                                VAN KAMPEN LIFE INVESTMENT TRUST
                                  | (31) Aggressive Growth               $________    (17) Strategic Stock                  $______
                                  | (29) International Growth            $________    OTHER: ___________________________    $______
                                  | (30) Worldwide Growth                $________
                                  |
                                  | J.P. MORGAN SERIES TRUST II
                                  | (32) J.P. Morgan Small Company       $________
                                  |
                                  | MFS VARIABLE INSURANCE TRUST
                                  | (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 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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AGLC0094 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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AGLCO094 REV 1101                                              PAGE 5 OF 5
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