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[LOGO] ALLMERICA SELECT ALLMERICA FINANCIAL LIFE INSURANCE AND ANNUITY COMPANY
A HIGHER STANDARD 440 LINCOLN STREET, WORCESTER, MA 01653
[ALLMERICA SELECT ADVOCATE]
VARIABLE ANNUITY APPLICATION
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1 MY INVESTMENT How much I want to invest.
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I am investing $________________ in Allmerica Select [Advocate.]
(Minimum $10,000. Make check payable to Allmerica Financial.)
If IRA, Roth, or SEP-IRA application, this payment is a (check one):
/ / Rollover/Conversion / / Trustee to Trustee Transfer
/ / Payment for Tax Year _______
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2 WHERE Where I want my money invested.
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Select your investment portfolio by allocating your dollars among the
accounts by percent or select one of the Model Portfolios below. Use
whole percentages.
_____ % Select Emerging Mkts. _____ % Select Gr. & Inc.
_____ % Select Int'l Equity _____ % Fidelity VIP Eq. Inc.
_____ % T. Rowe Price Int'l _____ % Fidelity VIP High Inc.
_____ % Select Aggr. Growth _____ % Select Inv. Grade Inc.
_____ % Select Capital Appr. _____ % Allmerica Money Mkt.
_____ % Select Value Opp. _____ % Fixed Account
_____ % Select Growth
_____ % Select Strategic Gr.
_____ % Fidelity VIP Growth
Guarantee Period Accounts (GPA) ($1,000 minimum per Account)
GPAS ARE NOT AVAILABLE IN MARYLAND, OREGON, PENNSYLVANIA
OR WASHINGTON.
____ % 3 Year ____ % 6 Year ____ % 8 Year
____ % 5 Year ____ % 7 Year ____ % 9 Year ____ % 10 Year
MODEL PORTFOLIOS
/ / Accumulator / / Builder / / Provider / / Saver / /Preserver
TOTAL OF ALL ALLOCATIONS MUST EQUAL 100%. FUTURE INVESTMENTS WILL BE ALLOCATED
TO THIS SELECTION UNLESS CHANGED BY ME.
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3 ACCOUNT REBALANCING
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/ / I elect Automatic Account Rebalancing of the VARIABLE
ACCOUNTS to the allocations specified in Section 2.
/ / Monthly / / Quarterly / / Semi-Annually / / Annually
AUTOMATIC ACCOUNT REBALANCING AND DOLLAR COST AVERAGING CANNOT
BE IN EFFECT SIMULTANEOUSLY.
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4 DOLLAR COST AVERAGING
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Select ONE account from which to transfer money.
Be sure you have allocated money to this account in Section 2.
Transfer $____________ ($100 Minimum)
FROM / / Fixed Account OR / / Select Income* OR / / Money Market*
(*This account cannot be selected in the allocation below.)
EVERY / / Month / / 3 Mos. / / 6 Mos. / / 12 Mos.
INTO:
_____ % Select Emerging Mkts. _____ % Select Strategic Gr.
_____ % Select Int'l Equity _____ % Fidelity VIP Growth
_____ % T. Rowe Price Int'l _____ % Select Gr. & Inc.
_____ % Select Aggr. Growth _____ % Fidelity VIP Eq. Inc.
_____ % Select Capital Appr. _____ % Fidelity VIP High Inc.
_____ % Select Value Opp. _____ % Select Inv. Grade Inc.
_____ % Select Growth _____ % Allmerica Money Mkt.
100 % Total
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5 THE OWNER Please Print Clearly
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OWNER'S First Name Middle Last
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Street Address
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City State Zip
- - / / / /M / / F
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Owner's Social Security Number Date of Birth/Trust Sex
( )
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Daytime Phone Number
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JOINT OWNER'S First Name Middle Last
- - / / / /M / / F
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Joint Owner's Social Security Number Date of Birth Sex
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6 THE ANNUITANT Please Print Clearly
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ANNUITANT'S First Name Middle Last
- - / / / /M / / F
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Annuitant's Social Security Number Date of Birth Sex
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JOINT ANNUITANT'S First Name Middle Last
- - / / / /M / / F
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Joint Annuitant's Social Security Number Date of Birth Sex
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7 BENEFICIARY Please Print Clearly
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If there are Joint Owners, the survivor is always Primary Beneficiary.
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Name of Primary Beneficiary Relationship to Owner
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Name of Contingent Beneficiary Relationship to Owner
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8 OPTIONAL RIDERS
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I elect: / / Enhanced Death Benefit
/ / __________________________________
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9 REPLACEMENT
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Will the proposed contract replace any existing annuity or life insurance
policy? / / Yes / / No
(If yes, list company name and policy number.)
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AS-693(5/00)
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10 TYPE OF ACCOUNT TO BE ISSUED
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(Check only one.)
/ / Non-Qualified / / Non-Qualified Deferred Comp.
/ / Regular IRA / / Roth IRA / / SEP-IRA*
/ / Deferred Compensation Plan (Section 457)*
*Attach required additional forms. Existing Case # ______________
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11 TELEPHONE AUTHORIZATION
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You will automatically be able to transfer account values, change the allocation
of future investments and obtain account values by telephone unless you check
the box below.
/ / I DO NOT accept this Telephone authorization.
(Please see additional information in Section 13 below.)
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12 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/LOUISIANA/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."
NOTICE TO FLORIDA RESIDENTS ONLY: "Any person who knowingly and with intent to injure, defraud, or
deceive any insurer files a statement of claim or an application containing a false, incomplete, or
misleading information is guilty of a felony of the third degree."
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13 SIGNATURES
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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 AMOUNT; 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 AN UPWARD OR
DOWNWARD ADJUSTMENT.
If I/we accepted the Telephone Authorization privilege in Section 11 above, I/we understand that
Allmerica Financial Life Insurance and Annuity Company is authorized to honor telephone requests by
any person who can furnish proper identification to transfer account values among Allmerica Select
investment options, change the allocation of my/our future investments and obtain account values.
Neither the Company nor its affiliates and their collective directors, officers, employees and
agents will be responsible for any claim arising from such action if the Company acted on
instructions in good faith in reliance on this authorization.
/ / Please send me a Statement of Additional Information (SAI).
/X/
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Signature of Owner Signed at (City and State) Date
/X/
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Signature of Joint Owner Signed at (City and State) Date
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14 FOR REGISTERED REP USE ONLY
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DOES THE CONTRACT APPLIED FOR REPLACE AN EXISTING ANNUITY OR LIFE INSURANCE POLICY(IES)? / / YES /
/ NO If yes, attach replacement forms as required. As Registered Representative, I certify
witnessing the signature of the applicant(s) 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(s) in this application, I certify that I have reasonable grounds for believing the
purchase of the contract applied for is suitable for the Owner(s). I further certify that the
Prospectuses were delivered and that no written sales materials other than those furnished or
approved by the Company were used.
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Signature of Registered Representative Print Name of Registered Representative Telephone
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Social Security # Florida License # Registered Rep # E-Mail Address
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Name of Broker/Dealer Branch #
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Branch Office Street Address for Contract Delivery City State Zip
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ALLMERICA SELECT - ALLMERICA FINANCIAL LIFE INSURANCE AND ANNUITY COMPANY
440 LINCOLN STREET - WORCESTER, MA 01653
AS-693 (5/00)
