<PAGE>
------------------ FIRST ALLMERICA FINANCIAL 440 Lincoln Street
ALLMERICA SELECT LIFE INSURANCE COMPANY Worcester, MA 01653
SPL APPLICATION
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
1 PAYMENT The monetary contribution to the policy.
--------------------------------------------------------------------------------
CHECK ONE:
/ / I have enclosed a check for my initial payment of $____________ and have
received a conditional receipt. (Please make check payable to First
Allmerica Financial Life Insurance Company)
/ / My initial payment will be transferred from another insurance company.
Approximate amount $____________. The amount of insurance purchased will be
the minimum allowed by the IRS Guideline Single Premium unless you
designate a higher amount $_________________________. (Please attach
Transfer of Assets form)
--------------------------------------------------------------------------------
2 ALLOCATION How I want my payment allocated.
--------------------------------------------------------------------------------
ALLOCATE MY PAYMENT AS FOLLOWS: Please use whole percentages. You may allocate
your payment to no more than 14 of the 14 variable accounts listed below and the
Fixed Account.
YOUR TOTAL ALLOCATION MUST EQUAL 100%
________ % Select Emerging Markets
________ % Select International Equity
________ % T. Rowe Price International Stock
________ % Select Aggressive Growth
________ % Select Capital Appreciation
________ % Select Value Opportunity
________ % Select Growth
________ % Select Strategic Growth
________ % Fidelity VIP Growth Portfolio
________ % Select Growth and Income
________ % Fidelity VIP Equity Income Portfolio
________ % Fidelity VIP High Income Portfolio
________ % Select Investment Grade Income
________ % Allmerica Money Market
________ % Fixed Account
________ %
________ %
________ %
________ %
100% % TOTAL
Any future payment will be allocated according to this selection unless changed
by me.
--------------------------------------------------------------------------------
3 ACCOUNT REBALANCING
--------------------------------------------------------------------------------
/ / I elect Automatic Account Rebalancing of the variable accounts to the
allocations specified in Section 2, above.
/ / Monthly / / Quarterly / / Semi-Annually / / Annually
(Automatic Account Rebalancing and Dollar Cost Averaging
cannot be in effect simultaneously.)
--------------------------------------------------------------------------------
4 DOLLAR COST AVERAGING
--------------------------------------------------------------------------------
Select ONE account from which to transfer money. Be sure you have money
allocated to this account in Section 2. Transfer $____________ ($100 Minimum)
FROM: / / Fixed Account or / / Select Investment Grade Income* or / / Money
Market* (*This account cannot be selected in the allocation below.)
EVERY: / / Month / / Quarter / / 6 Mos. / / 12 Mos.
INTO: ________ % Select Emerging Markets
________ % Select International Equity
________ % T. Rowe Price International Stock
________ % Select Aggressive Growth
________ % Select Capital Appreciation
________ % Select Value Opportunity
________ % Select Growth
________ % Select Strategic Growth
________ % Fidelity VIP Growth Portfolio
________ % Select Growth and Income
________ % Fidelity VIP Equity Income Portfolio
________ % Fidelity VIP High Income Portfolio
________ % Select Investment Grade Income
________ % Allmerica Money Market
________ %
________ %
________ %
________ %
100% % TOTAL
--------------------------------------------------------------------------------
5 INSURED The person upon whose life this insurance coverage is proposed.
For second insured, complete Form AS-426
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
First Name Middle Last
--------------------------------------------------------------------------------
Street Address
--------------------------------------------------------------------------------
City State Zip
( )
--------------------------------------------------------------------------------
Daytime Telephone Number Years at this Address
____/____/____
Date of Birth / / M / / F ----------------
Sex State of Birth
------------------------------- -----------------------
Social Security/Tax I.D. Number Driver's License Number
--------------------------------------------------------------------------------
6 OWNER The person or entity exercising the policy's contractual rights.
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
First Name Middle Last
--------------------------------------------------------------------------------
Street Address
--------------------------------------------------------------------------------
City State Zip
------------------------------- -----------------------
Social Security/Tax I.D. Number Date of Trust
AS-401NY REV 6/00
Page 1
<PAGE>
-------------------------------------------------------------------------------
7 BENEFICIARY
-------------------------------------------------------------------------------
-------------------------------------------------------------------------------
Name of Primary Beneficiary Relationship to Insured
-------------------------------------------------------------------------------
Name of Contingent Beneficiary Relationship to Insured
-------------------------------------------------------------------------------
8 REPLACEMENT OF OTHER CONTRACTS
-------------------------------------------------------------------------------
WILL THE PROPOSED POLICY REPLACE ANY EXISTING ANNUITY OR LIFE
INSURANCE POLICY?
/ / Yes / / No
If yes, list company name and policy number:
-------------------------------------------------------------------------------
-------------------------------------------------------------------------------
-------------------------------------------------------------------------------
9 INFORMATION ABOUT THE INSURED
-------------------------------------------------------------------------------
10a CURRENT EMPLOYMENT.
Employer's Name: _________________________________________________________
Occupation and Responsibilities: _________________________________________
_______________________________________________________________________________
10b INCOME
My annual earned income is $______________
My annual unearned income is $______________
My net worth is $______________
10c DURING THE PAST YEAR, I HAVE SMOKED ONE OR MORE CIGARETTES, CIGARS, PIPES,
OR USED CHEWING TOBACCO.
/ / Yes / / No
10d Height________________________________ Weight_____________________________
-------------------------------------------------------------------------------
10 MEDICAL HISTORY
-------------------------------------------------------------------------------
11a DURING THE PAST 10 YEARS, I HAVE HAD, OR BEEN TREATED FOR HEART, LIVER,
LUNG, OR KIDNEY TROUBLE, HIGH BLOOD PRESSURE, STROKE, DIABETES, CANCER,
NERVOUS OR PSYCHOLOGICAL DISORDERS, OR ALCOHOL OR DRUG ABUSE.
/ / Yes / / No
11b DURING THE PAST 10 YEARS, I HAVE HAD, OR BEEN TREATED FOR IMMUNE SYSTEM
DISORDER INCLUDING ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS), AIDS-RELATED
COMPLEX, OR ANOTHER IMMUNE DISORDER.
/ / Yes / / No
IF YOU ANSWERED "YES " TO 11a OR 11b, PLEASE COMPLETE ITEMS 11c THROUGH 11f:
11c I HAVE BEEN DIAGNOSED OR TREATED FOR:_____________________________________
-------------------------------------------------------------------------------
-------------------------------------------------------------------------------
-------------------------------------------------------------------------------
-------------------------------------------------------------------------------
I AM CURRENTLY BEING TREATED: / / YES / / NO
-------------------------------------------------------------------------------
Primary Physician's Name
-------------------------------------------------------------------------------
Health Care Provider
-------------------------------------------------------------------------------
Street Address
-------------------------------------------------------------------------------
City State Zip
( ) / /
-------------------------------------------------------------------------------
Telephone Date of Last Visit
11d DURING THE PAST THREE YEARS, I HAVE PARTICIPATED IN, OR INTEND TO
PARTICIPATE IN:
/ / Scuba Diving / / Skydiving / /Land/Water Racing
/ / Hang Gliding or similar flying activity
11e DURING THE PAST TWO YEARS, I HAVE FLOWN, OR INTEND TO FLY, AS A TRAINEE,
PILOT, OR CREW MEMBER.
/ / Yes / / No
11f DURING THE PAST THREE YEARS, I HAVE HAD A MOTOR VEHICLE LICENSE SUSPENDED
OR REVOKED, OR BEEN CONVICTED OF DRIVING WHILE INTOXICATED OR OF MORE THAN
ONE MOVING VIOLATION.
/ / Yes / / No
AS-401NY Page 2
<PAGE>
--------------------------------------------------------------------------------
AUTHORIZATIONS AND SIGNATURES
--------------------------------------------------------------------------------
AUTHORIZATION TO OBTAIN INFORMATION
To all physicians, medical professionals, hospitals, clinics, other health care
providers, employers, Medical Information Bureau, Inc. (MIB), consumer reporting
agencies, other insurance support organizations, the United States Internal
Revenue Service, the Puerto Rico Bureau of Income Tax, and other persons who
have the types of information described about the proposed Insured:
I authorize you to give the Company, its reinsurers, or its agent (a) all
information you have as to illness, injury, medical history, diagnosis,
treatment, and prognosis (including any drug or alcohol abuse condition or
treatment) with respect to any physical or mental condition of the proposed
Insured; and (b) any non-medical information, including but not limited to, an
investigative consumer report and copies of my tax returns filed with the United
States Internal Revenue Service and/or Puerto Rico Bureau of Income Tax, which
the Company believes it needs to perform the business functions described below.
I also authorize the Company to give the MIB health or non-medical information
it has about me and that of any minor member of my family applying for
insurance.
The information obtained will be used to determine if the proposed Insured is
eligible for: (a) the insurance requested; or (b) benefits under a policy which
is in force. It will also be used for any other business purpose which relates
to the insurance requested or the policy which is in force. This authorization
will be valid for 30 months. I know that under Federal Regulations I may revoke
this authorization as it applies to drug and alcohol abuse treatment at any
time, but my revocation will not effect any information that has been released
prior thereto. I know that I may request a copy of this form. I agree that a
photocopy is as valid as the original. I have received the Insurance Information
Practices notice.
VARIABLE PRODUCT DISCLOSURE
I UNDERSTAND THAT ANY DEATH BENEFITS IN EXCESS OF THE FACE AMOUNT AND ANY POLICY
VALUE OF THE POLICY APPLIED FOR, MAY INCREASE OR DECREASE TO REFLECT THE
INVESTMENT EXPERIENCE OF THE SUB-ACCOUNTS OF THE VARIABLE ACCOUNT. THE POLICY
VALUE ALLOCATED TO THE FIXED ACCOUNT WILL ACCUMULATE INTEREST AT A RATE SET BY
THE COMPANY WHICH WILL NOT BE LESS THAN THE MINIMUM GUARANTEED RATE OF 4%
ANNUALLY. THERE IS NO GUARANTEED MINIMUM POLICY VALUE. THE POLICY VALUE MAY
DECREASE TO THE POINT WHERE THE POLICY WILL LAPSE AND PROVIDE NO FURTHER DEATH
BENEFIT WITHOUT ADDITIONAL PAYMENTS.
ACKNOWLEDGEMENTS AND AGREEMENTS
I acknowledge receipt of current Prospectuses describing the First Allmerica
Select SPL policy that I am applying for, and the underlying funds.
It is agreed that: (1) The application consists of this application form, the
medical questionnaire, if any, and the information on the Second Insured form,
if it applies; (2) The representations are true and complete to the best of my
knowledge and belief; (3) No liability exists and the insurance applied for will
not take effect until the policy is delivered and the payment is made during the
lifetime of the proposed Insured(s) and then only if the proposed Insured(s) has
(have) not consulted any physician or practitioner of any healing art nor had
any tests listed in the application since its completion; but if the payment is
paid prior to delivery of the policy and a conditional receipt is delivered by
the registered representative, insurance will be effective subject to the terms
of the conditional receipt; and (4) No registered representative or broker is
authorized to amend, alter, or modify the terms of this agreement.
--------------------------------------------------------------------------------
Signature of Insured Date
--------------------------------------------------------------------------------
Print Name of Insured
--------------------------------------------------------------------------------
Signed at City State
--------------------------------------------------------------------------------
Signature of Owner (if other than Insured) Date
--------------------------------------------------------------------------------
Print Name of Owner
--------------------------------------------------------------------------------
Signed at City State
AS-401NY Page 3
<PAGE>
--------------------------------------------------------------------------------
FOR FINANCIAL REPRESENTATIVE USE ONLY
--------------------------------------------------------------------------------
Does the policy applied for replace an existing annuity or life insurance
policy?
/ / Yes / / No
If yes, attach replacement forms as required.
As Registered Representative, I certify witnessing the signature of the
applicant and that the information in this application has been accurately
recorded to the best of my knowledge and belief.
Based on the information furnished by the Owner or Insured in this application,
I certify that I have reasonable grounds for believing the purchase of the
policy applied for is suitable for the Owner. I further certify that the
Prospectuses were delivered and that no written sales materials other than those
furnished by the Company were used.
--------------------------------------------------------------------------------
Signature of Registered Representative Date
--------------------------------------------------------------------------------
Print Name of Registered Representative Reg Rep #
--------------------------------------------------------------------------------
Social Security Number (required)
--------------------------------------------------------------------------------
TR Code
( ) ( )
--------------------------------------------------------------------------------
Telephone Fax
--------------------------------------------------------------------------------
Name of Broker/Dealer Branch #
--------------------------------------------------------------------------------
Branch Office Street Address
--------------------------------------------------------------------------------
City State Zip
REMARKS: _______________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
--------------------------------------------------------------------------------
FOR HOME OFFICE USE ONLY
--------------------------------------------------------------------------------
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
AS-401NY Page 4
<PAGE>
---------------- FIRST ALLMERICA FINANCIAL 440 Lincoln Street
ALLMERICA SELECT LIFE INSURANCE COMPANY Worcester, Ma 01653
INFORMATION ON SECOND INSURED
SPL APPLICATION
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
1 SECOND INSURED
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
First Name Middle Last
--------------------------------------------------------------------------------
Street Address
--------------------------------------------------------------------------------
City State Zip
( )
--------------------------------------------------------------------------------
Daytime Telephone Number Years at this Address
/ / / /M / /F
---------------- --------------
Date of Birth Sex State of Birth
--------------------------------------------------------------------------------
Social Security/Tax I.D. Number Driver's License Number
--------------------------------------------------------------------------------
2 OWNER AND BENEFICIARY
--------------------------------------------------------------------------------
The Owner and Beneficiary are as indicated in Section 6 and 7 of the
accompanying SPL application. If Section 6 is left blank, the Owner will be the
insured listed in Section 5 of the SPL application.
--------------------------------------------------------------------------------
3 REPLACEMENT OF OTHER CERTIFICATES
--------------------------------------------------------------------------------
WILL THE PROPOSED POLICY REPLACE ANY EXISTING ANNUITY OR LIFE INSURANCE POLICY?
/ / Yes / / No
If yes, list company name and policy number:
________________________________________________________________________________
________________________________________________________________________________
--------------------------------------------------------------------------------
4 INFORMATION ABOUT THE INSURED
--------------------------------------------------------------------------------
4a CURRENT EMPLOYMENT.
Employer's Name: ____________________________________________________________
Occupation and Responsibilities: ____________________________________________
_____________________________________________________________________________
4b INCOME
My annual earned income is $_________________________________________
My annual unearned income is $_________________________________________
My net worth is $_________________________________________
4c DURING THE PAST YEAR, I HAVE SMOKED ONE OR MORE CIGARETTES, CIGARS, PIPES, OR
USED CHEWING TOBACCO.
/ / Yes / / No
4d Height____________________________ Weight____________________________
--------------------------------------------------------------------------------
5 MEDICAL HISTORY
--------------------------------------------------------------------------------
5a DURING THE PAST 10 YEARS, I HAVE HAD, OR BEEN TREATED FOR HEART, LIVER,
LUNG, OR KIDNEY TROUBLE, HIGH BLOOD PRESSURE, STROKE, DIABETES, CANCER,
NERVOUS OR PSYCHOLOGICAL DISORDERS, OR ALCOHOL OR DRUG ABUSE.
/ / Yes / / No
5b DURING THE PAST 10 YEARS, I HAVE HAD, OR BEEN TREATED FOR IMMUNE SYSTEM
DISORDER INCLUDING ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS), AIDS-RELATED
COMPLEX, OR ANOTHER IMMUNE DISORDER.
/ / Yes / / No
IF YOU ANSWERED "YES" TO 5a OR 5b, PLEASE COMPLETE ITEMS 5c THROUGH 5f:
5c I HAVE BEEN DIAGNOSED OR TREATED FOR:________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
I AM CURRENTLY BEING TREATED: / / YES / / NO
-----------------------------------------------------------------------------
Primary Physician's Name
-----------------------------------------------------------------------------
Health Care Provider
-----------------------------------------------------------------------------
Street Address
-----------------------------------------------------------------------------
City State Zip
( )
-------------------------------------- -------------------
Telephone Date of Last Visit
5d DURING THE PAST THREE YEARS, I HAVE PARTICIPATED IN, OR INTEND TO
PARTICIPATE IN:
/ / Scuba Diving / / Skydiving / / Land/Water Racing
/ / Hang Gliding or similar flying activity
5e DURING THE PAST TWO YEARS, I HAVE FLOWN, OR INTEND TO FLY, AS A TRAINEE,
PILOT, OR CREW MEMBER.
/ / Yes / / No
5f DURING THE PAST THREE YEARS, I HAVE HAD A MOTOR VEHICLE LICENSE SUSPENDED
OR REVOKED, OR BEEN CONVICTED OF DRIVING WHILE INTOXICATED OR OF MORE THAN
ONE MOVING VIOLATION.
/ / Yes / / No
AS-426NY Page 1
<PAGE>
--------------------------------------------------------------------------------
AUTHORIZATION AND SIGNATURES
--------------------------------------------------------------------------------
AUTHORIZATION TO OBTAIN INFORMATION
To all physicians, medical professionals, hospitals, clinics, other health care
providers, employers, Medical Information Bureau, Inc. (MIB), consumer reporting
agencies, other insurance support organizations, the United States Internal
Revenue Service, the Puerto Rico Bureau of Income Tax, and other persons who
have the types of information described about the proposed Insured:
I authorize you to give the Company, its reinsurers, or its agent (a) all
information you have as to illness, injury, medical history, diagnosis,
treatment, and prognosis (including any drug or alcohol abuse condition or
treatment) with respect to any physical or mental condition of the proposed
Insured; and (b) any non-medical information, including but not limited to, an
investigative consumer report and copies of my tax returns filed with the United
States Internal Revenue Service and/or Puerto Rico Bureau of Income Tax, which
the Company believes it needs to perform the business functions described below.
I also authorize the Company to give the MIB health or non-medical information
it has about me and that of any minor member of my family applying for
insurance.
The information obtained will be used to determine if the proposed Insured is
eligible for: (a) the insurance requested; or (b) benefits under a policy which
is in force. It will also be used for any other business purpose which relates
to the insurance requested or the policy which is in force. This authorization
will be valid for 30 months. I know that under Federal Regulations I may revoke
this authorization as it applies to drug and alcohol abuse treatment at any
time, but my revocation will not effect any information that has been released
prior thereto. I know that I may request a copy of this form. I agree that a
photocopy is as valid as the original. I have received the Insurance Information
Practices notice.
ACKNOWLEDGEMENTS AND AGREEMENTS
It is agreed that: (1) The application consists of this application form, the
medical questionnaire, if any, and the information on the Second Insured form;
(2) The representations are true and complete to the best of my knowledge and
belief; (3) No liability exists and the insurance applied for will not take
effect until the policy is delivered and the payment is made during the lifetime
of the proposed Insured(s) and then only if the proposed Insured(s) has (have)
not consulted any physician or practitioner of any healing art nor had any tests
listed in the application since its completion; but if the payment is paid
prior to delivery of the policy and a conditional receipt is delivered by the
registered representative, insurance will be effective subject to the terms of
the conditional receipt; and (4) No registered representative or broker is
authorized to amend, alter, or modify the terms of this agreement.
--------------------------------------------------------------------------------
Signature of Second Insured Date
--------------------------------------------------------------------------------
Print Name of Second Insured
--------------------------------------------------------------------------------
Signed at City State
--------------------------------------------------------------------------------
Signature of Owner (if other than Insured) Date
--------------------------------------------------------------------------------
Print Name of Owner
--------------------------------------------------------------------------------
Signed at City State
AS-426NY Page 2
