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Exhibit 1(10)
First Allmerica Financial 440 Lincoln Street ESTATE OPTIMIZER LIFE
[LOGO] Life Insurance Company Worcester, MA 01653 INSURANCE APPLICATION
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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 $____________. My present contract has a loan that I
wish to carry over to the new contract / /yes / /no
Loan carry over amount $____________
Total approximate transfer amount $____________
(Transfer payment & loan carry over)
(Please attach Transfer of Assets form)
The amount of insurance purchased will be the minimum allowed by the IRS
Guideline Single Premium unless you designate a higher amount
$_________________________.
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 20 of the 21 variable accounts listed below and the
Fixed Account.
YOUR TOTAL ALLOCATION MUST EQUAL 100%
________ % Allmerica Select Aggressive Growth
________ % Allmerica Select Capital Appreciation
________ % Allmerica Select Value Opportunity Fund
________ % Allmerica Select Emerging Markets
________ % T. Rowe Price International Stock
________ % Fidelity VIP Overseas Portfolio
________ % Allmerica Select International Equity
________ % Delaware International Equity Series
________ % Fidelity VIP Growth Portfolio
________ % Allmerica Select Growth
________ % Allmerica Select Strategic Growth
________ % Allmerica Growth
________ % Allmerica Equity Index
________ % Fidelity VIP Equity Income Portfolio
________ % Allmerica Select Growth and Income
________ % Fidelity VIP II Asset Manager
________ % Fidelity VIP High Income Portfolio
________ % Allmerica Investment Grade Income
________ % Allmerica Select Income
________ % Allmerica Government Bond Fund
________ % 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
/ / Government Bond Fund* or / /Money Market*
(*This account cannot be selected in the allocation below.)
EVERY: / / Month / / Quarter / / 6 Mos. / / 12 Mos.
INTO: ________ % Allmerica Select Aggressive Growth
________ % Allmerica Select Capital Appreciation
________ % Allmerica Select Value Opportunity Fund
________ % Allmerica Select Emerging Markets
________ % T. Rowe Price International Stock
________ % Fidelity VIP Overseas Portfolio
________ % Allmerica Select International Equity
________ % Delaware International Equity Series
________ % Fidelity VIP Growth Portfolio
________ % Allmerica Select Growth
________ % Allmerica Select Strategic Growth
________ % Allmerica Growth
________ % Allmerica Equity Index
________ % Fidelity VIP Equity Income Portfolio
________ % Allmerica Select Growth and Income
________ % Fidelity VIP II Asset Manager
________ % Fidelity VIP High Income Portfolio
________ % Allmerica Investment Grade Income
________ % Allmerica Select Income
________ % Allmerica Government Bond Fund
________ % Allmerica Money Market
________ %
________ %
100% % TOTAL
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5 INSURED The person upon whose life this insurance coverage is proposed.
For second insured, complete form 10495.
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First Name Middle Last
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Street Address
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City State Zip
( )
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Daytime Telephone Number Years at this Address
----/----/---- / /M / /F --------------------------
Date of Birth Sex State of Birth
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Social Security/Tax I.D. Number Driver's License Number
6 OWNER The person or entity exercising the policy's contractual rights.
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First Name Middle Last
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Street Address
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City State Zip
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Social Security/Tax I.D. Number Date of Trust
7 BENEFICIARY
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Name of Primary Beneficiary Relationship to Insured
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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:
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9 INFORMATION ABOUT THE INSURED
9a CURRENT EMPLOYMENT.
Employer's Name: _____________________________________
Occupation and Responsibilities: _____________________
______________________________________________________
9b INCOME
My annual earned income is $_________________
My annual unearned income is $_________________
My net worth is $_________________
9c DURING THE PAST YEAR, I HAVE SMOKED ONE OR MORE CIGARETTES, CIGARS, PIPES,
OR USED CHEWING TOBACCO.
/ / Yes / / No
9d Height_______________ Weight_______________
10 MEDICAL HISTORY
10a 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
10b 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
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Primary Physician's Name
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Health Care Provider
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Street Address
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City State Zip
( )
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Telephone Date of Last Visit
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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
12 SUITABILITY Insureds, owners, and agents must review and complete this
section.
12a REASON FOR INSURANCE:
/ / Estate Taxes / / Fund Business Agreement
/ / Retirement Income / / Death Benefit
/ / Business Insurance / / Gift
/ / Family Income / / Other
/ / Cash Accumulation
12b OWNER'S ESTIMATED FINANCIAL DATA:
Securities: $____________Savings: $ _____________
Liquid Net Worth: $__________ Tax Bracket: ______%
Gross Annual Income: $ __________________________
12c RISK PROFILE:
/ /Conservative / / Moderate / / Aggressive
Source of Funds:_________________________________
12d INVESTMENT OBJECTIVE:
/ / Emphasizes Growth / / Emphasizes Stability
/ / Balances Growth and Stability
12e ARE ANY ANNUITIES, MUTUAL FUNDS, OR SECURITIES BEING LIQUIDATED TO PURCHASE
THIS VARIABLE LIFE INSURANCE POLICY?
/ / Yes / / No
If yes, a switching letter signed by the policyowner is attached:
/ / Yes / / No
If yes, has the agent explained the potential advantages and disadvantages
of this transaction?:
/ / Yes / / No
12f ARE YOU AN ASSOCIATED PERSON OF ANOTHER BROKER OR DEALER?
/ / Yes / / No
12g HAVE YOU RECEIVED A CURRENT PROSPECTUS DESCRIBING THE VARIABLE LIFE
INSURANCE POLICY, INCLUDING THE UNDERLYING FUNDS, AND DO YOU BELIEVE THAT A
FLEXIBLE-PREMIUM VARIABLE LIFE INSURANCE POLICY IS CONSISTENT WITH YOUR
INVESTMENT OBJECTIVES AND FINANCIAL NEEDS?
/ / Yes / / No
AUTHORIZATION:
_________________________________________________ ___________
(Completed by a Home Office Registered Principal) Date
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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 Estate Optimizer
Life Insurance 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.
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Signature of Insured Date
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Print Name of Insured
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Signed at City State
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Signature of Owner (if other than Insured) Date
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Print Name of Owner
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Signed at City State
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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.
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Signature of Registered Representative Date
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Print Name of Registered Representative Reg Rep #
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TR Code Split %
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Signature of Registered Representative Date
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Print Name of Registered Representative Reg Rep #
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TR Code Split %
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Signature of Registered Representative Date
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Print Name of Registered Representative Reg Rep #
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TR Code Split %
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Signature of Registered Representative Date
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Print Name of Registered Representative Reg Rep #
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TR Code Split %
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Telephone Fax
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Name of Broker/Dealer Branch #
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Branch Office Street Address
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City State Zip
REMARKS:
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FOR HOME OFFICE USE ONLY
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INFORMATION ON SECOND INSURED
First Allmerica Financial 440 Lincoln Street ESTATE OPTIMIZER LIFE
[LOGO] Life Insurance Company Worcester, MA 01653 INSURANCE APPLICATION
1 SECOND INSURED
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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 Estate Optimizer Life Insurance Application. If Section 6 is left
blank, the Owner will be the insured listed in Section 5 of the Estate Optimizer
Life Insurance 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
1
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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.
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 representa-tions 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 pay-ment 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.
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Signature of Second Insured Date
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Print Name of Second Insured
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Signed at City State
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Signature of Owner (if other than Insured) Date
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Print Name of Owner
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Signed at City State
2
