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[KEMPER SECONDARY B/D] ALLMERICA FINANCIAL LIFE INSURANCE
[LOGO] KEMPER ANNUITIES AND ANNUITY COMPANY
Long-term investing in a short-term world SM 440 LINCOLN STREET, WORCESTER, MA 01653
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1. OWNER(S) Please Print Clearly
First MI Last
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Street Address
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City State Zip
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Social Security/Tax I.D. Date of Birth/Trust Male
- - / / Female
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Daytime Telephone
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JOINT OWNER First MI Last
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Social Security/Tax I.D. Date of Birth Male
- - / / Female
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Daytime Telephone
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2. ANNUITANTS(S) Please Print Clearly
First MI Last
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Social Security/Tax I.D. Date of Birth Male
- - / / Female
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JOINT ANNUITANT First MI Last
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Social Security/Tax I.D. Date of Birth Male
- - / / Female
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3. BENEFICIARY (If beneficiary is a trust, provide date of trust)
If there are Joint Owners, the survivor is always Primary Beneficiary.
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Primary Beneficiary Relationship to Owner
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Primary Beneficiary Relationship to Owner
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Contingent Beneficiary Relationship to Owner
4. OPTIONAL RIDERS
I/We elect: / / Enhanced Death Benefit
/ /
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5. TYPE OF PLAN TO BE ISSUED:
/ / Nonqualified / / IRA
/ / Nonqualified Def. Comp. / / Roth IRA
/ / 401(a) Pension/Profit Sharing* / / SEP-IRA*
/ / 401(k) Profit Sharing* / / 457 Def. Comp.*
/ / 403(b) TSA*
*Attach required additional forms. Existing Case #
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6. INITIAL PAYMENT
Initial Payment $
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($2,000 minimum-Make check payable to Allmerica Financial.)
If IRA, Roth IRA or SEP-IRA application, this payment is a:
/ / Rollover/Conversion / / Trustee to Trustee Transfer
/ / Payment for Tax Year
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7. AllOCATION OF PAYMENTS
KEMPER SCUDDER VLIF
_________ % Agg Gro _________ % Int'l
_________ % Tech Gro _________ % Glb D
_________ % Drm Fin _________ % Cap G
_________ % SC Grow _________ % Gro&I
_________ % SC Val
_________ % Drm Hi Ret ALGER
_________ % Int'l _________ % IV Al
_________ % Int'l G&I _________ % Balcd
_________ % Glb BlChp
_________ % Growth DREYFUS
_________ % Cont Val _________ % Soc R
_________ % Bl Chip _________ % Midcp
_________ % Val+Gro
_________ % Indx 500 FIXED ACCOUNT
_________ % Horz 20+ _________ % Fxd A
_________ % Total Ret
_________ % Horz 10+ GUARANTEE PERIOD ACCOUNTS
_________ % High Yld ($1,000 minimum per Account)
_________ % Horz 5+ (GPA) NOT APPROVED IN MD, OR, PA, WA
_________ % Glb Inc _________ % 2 Yr. Guarantee Period
_________ % Inv Grd Bd _________ % 3 Yr. Guarantee Period
_________ % Gov Sec _________ % 4 Yr. Guarantee Period
_________ % Money Mkt _________ % 5 Yr. Guarantee Period
_________ _________ % 6 Yr. Guarantee Period
KVS _________ % 7 Yr. Guarantee Period
_________ % Fc LC Gro (Eagle) _________ % 8 Yr. Guarantee Period
_________ % Gro Opp (Janus) _________ % 9 Yr. Guarantee Period
_________ % Gro & Inc. (Janus) _________ % 10 Yr. Guarantee Period
All allocations above must total 100%
8. SECURE YOUR FUTURE PROGRAM
/ / Allocate a portion of my/our initial payment to _____ year GPA such that, the
at the end of the Guarantee Period, the GPA will have grown to an amount equal to
the total initial payment assuming no withdrawals or transfers of any kind. The
remaining balance will be applied as indicated above in Section 7.
9. AUTOMATIC ACCOUNT REBALANCING (AAR)
/ / I/We elect Automatic Account Rebalancing (AAR) among the above variable
accounts every:
/ / 1 Mo. / / 2 Mos. / / 3 Mos. / / 6 Mos. / / 12 Mos.
10. TELEPHONE AUTHORIZATION
I/We authorize and direct Allmerica Financial to accept telephone instructions
from any person who can furnish proper identification to effect transfers,
future payment allocation changes and obtain values. Neither Allmerica Financial
nor its affiliates and their collective directors, officers, employees and
agents responsible for any claim arising from such action if Allmerica Financial
acted on instructions in good faith in reliance on this authorization.
/ / I/We DO NOT accept this telephone authorization.
11. REPLACEMENT
Will the proposed contract replace or change any existing annuity or insurance
policy?
/ / No / / Yes (If yes, list company name and policy number)
SML-1513K
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12. DOLLAR COST AVERAGING
(Not available with Automatic Account Rebalancing)
Please transfer $______________ from (check one source account):
($100 minimum)
(Be sure you have allocated money to the Source Account in Section 7.)
/ / Fixed Account / / Government Securities / / Money Market
Every: / / 1 Mo. / / 2 Mos. / / 3 Mos. / / 6 Mos. / / 12 Months
TO: KEMPER
________ % Agg Gro ________ % Gov Sec
________ % Tech Gro ________ % Money Mkt
________ % Drm Fin
________ % SC Grow KVS
________ % SC Val ________ % Fc LC Gro (Eagle)
________ % Drm Hi Ret ________ % Gro Opp (Janus)
________ % Int'l ________ % Gro & Inc. (Janus)
________ % Int'l G&I
________ % Glb BlChp SCUDDER VLIF
________ % Growth ________ % Int'l
________ % Cont Val ________ % Glb Disc
________ % Bl Chip ________ % Cap Gro
________ % Val+Gro ________ % Gro&Inc
________ % Indx 500
________ % Horz 20+ ALGER
________ % Total Ret ________ % Lv AllCap
________ % Horz 10+ ________ % Balcd
________ % High Yld
________ % Horz 5+ DREYFUS
________ % Glb Inc ________ % Soc Rp Gro
________ % Inv Grd Bd ________ % Midcp Stk
DCA into the Fixed or Guarantee Period Account is not available.
13. SYSTEMATIC WITHDRAWALS
A. Frequency (Please choose one):
/ / 1 Mo. / / 2 Mos. / / 3 Mos. / / 6 Mos. / / 12 Mos.
Withdrawals begin later of 15 days after issue or ____/____ /____.
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B. Program (Please choose one):
1. / / Systematic Withdrawal without surrender
charge
/ / Maximum (12% of payment per calendar year)
/ / $_____________ per frequency
or
2. / / Systematic Withdrawal (May incur surrender charges)
/ / $__________________ per frequency
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C. Withdraw from:
Systematic withdrawals are not available from the Guarantee Period Accounts
/ / Pro-Rata from all accounts, OR:
______________% From _____________________________________________
______________% From _____________________________________________
______________% From _____________________________________________
______________% From _____________________________________________
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D. PLEASE / / Do Not Withhold Federal Income Taxes
/ / Do Withhold at 10% or __________________ (% or $)
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E. / / I/We wish to use Electronic Funds Transfer (Direct Deposit).
I/We authorize Allmerica Financial to correct electronically
any overpayments or erroneous credits made to my contract.
ATTACH VOIDED CHECK
14. REMARKS
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NOTICE TO ARKANSAS/NEW JERSEY/OHIO RESIDENTS ONLY: "Any person who includes any
false or misleading information on an application for an insurance
policy/certificate is subject to criminal and civil penalties."
NOTICE TO COLORADO/KENTUCKY/MAINE/NEW MEXICO/PENNSYLVANIA/WASHINGTON, D.C.
RESIDENTS ONLY: "Any person who knowingly and with intent to defraud any
insurance company or other person files an application for insurance or
statement of claim containing any materially false information or conceals
for the purpose of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, which is a crime and subjects
such person to criminal and civil penalties."
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15. SIGNATURES
I/We represent to the best of my/our knowledge and belief that the statements
made in this application are true and complete. I/We agree to all terms and
conditions as shown on the front and back. It is indicated and agreed that the
only statements which are to be construed as the basis of the contract are those
contained in this application. I/We acknowledge receipt of a current prospectus
describing the contract applied for. If IRA, Roth, or SEP-IRA application, I/WE
HAVE RECEIVED A DISCLOSURE BUYER'S GUIDE. I/WE UNDERSTAND THAT ALL PAYMENTS AND
VALUES BASED ON THE VARIABLE ACCOUNTS MAY FLUCTUATE AND ARE NOT GUARANTEED AS TO
DOLLAR AMOUNTS AND ALL PAYMENTS AND VALUES BASED ON THE GUARANTEE PERIOD
ACCOUNTS (WHERE GPAS ARE AVAILABLE) ARE SUBJECT TO A MARKET VALUE ADJUSTMENT
FORMULA (IF APPLICABLE), THE OPERATION OF WHICH MAY RESULT IN EITHER UPWARD OR
DOWNWARD ADJUSTMENT.
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Signature of Owner Signed at (City and State) Date
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Signature of Joint Owner Signed at (City and State) Date
16. REGISTERED REPRESENTATIVE / DEALER INFORMATION
DOES THE CONTRACT APPLIED FOR REPLACE AN EXISTING ANNUITY OR LIFE INSURANCE POLICY?
/ / YES (ATTACH REPLACEMENT FORMS REQUIRED) / / NO
I certify that the information provided by the owner has been accurately
recorded; a current prospectus was delivered; no written sales materials other
than those approved by the Principal Office were used; and I have reasonable
grounds to believe the purchase of the contract applied for is suitable for the
owner.
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Signature of Registered Representative Comm. Code SSN# Telephone
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Printed Name of Registered Representative B/D Client Acct. # Printed Name of Broker/Dealer
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Branch Office Street Address for Contract Delivery Telephone of Broker/Dealer
OVERNIGHT MAIL TO: 66 Brooks Drive Braintree, MA 02184
Mail To: P.O. Box 8632, Boston, MA 02266-8632
SML-1513K
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