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[LOGO] ALLMERICA FINANCIAL
LIFE INSURANCE AND 440 Lincoln Street ULTIMATE ADVANTAGE
ANNUITY COMPANY Worcester, MA 01653 VARIABLE ANNUITY APPLICATION
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Please Print Clearly Please Print Clearly
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1. OWNER
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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/Trust / / Male
/ / / / Female
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Daytime Telephone
( )
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2. ANNUITANT
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Check one and fill in below:
/ / The owner is other than the annuitant, or
/ / This is a joint owner with the annuitant.
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
Social Security/Tax I.D. Date of Birth/Trust / / Male
/ / / / Female
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Daytime Telephone
( )
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3. BENEFICIARY
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If there are Joint Owners, the survivor is always Primary Beneficiary.
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Primary Relationship to Owner
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Primary Relationship to Owner
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Contingent Relationship to Owner
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4. TYPE OF PLAN
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/ / 408(b) IRA / / 457 Def. Comp.
/ / Roth IRA / / Non-Qual. Def. Comp.
/ / 408(k) SEP-IRA* / / Non-Qualified
*Attach required additional forms.
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5. OPTIONAL RIDERS
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/ / Minimum Guaranteed Annuity Payout:* / / 10 yr. / / 15 yr.
/ / Enhanced Death Benefit Rider* / / 10 yr. / / 15 yr.
*NOT AVAILABLE IN ALL STATES.
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6. INITIAL PAYMENT
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Initial Payment $ _______________________________________
($5,000 Minimum - Make check payable to Allmerica Financial)
If IRA, Roth IRA or SEP-IRA application, the applicant has received a
Disclosure Buyer's Guide and this payment is a
(check one):
/ / Rollover / / Trustee to Trustee Transfer
/ / IRA or SEP-IRA Payment for Tax Year ________________
/ / Roth IRA
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7. REPLACEMENT
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Will the proposed contract replace or change any existing
annuity or insurance policy? / / No / / Yes
(If yes, list company name and policy number)
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8. ALLOCATION OF PAYMENTS
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_______ % Pio Emerg Mkt _______ % Invesco Hlth Sc
_______ % Sel Emg Mkt _______ % KVS Fin'l Scvs
_______ % All Sel Int'l Eq _______ % Frkln Nat Rsrcs
_______ % DGPF Int'l Eq _______ % All Sel Gro
_______ % Fid VIP Overseas _______ % Core Equity
_______ % T. R Pr Int'l Stk _______ % Fid VIP Gro
_______ % AIM Aggr Growth _______ % Janus Gro & Inc
_______ % Frkln Small Cap _______ % Alliance Gro & Inc
_______ % Sel Strat Gro _______ % Pio Real Estate
_______ % All Sel Aggr Gro _______ % All Eq Index
_______ % All Sel Cap App _______ % All Sel Gro & Inc
_______ % All Sel Val Opp _______ % Fid VIP Eq-Inc
_______ % Janus Aspen Gro _______ % Fid VIP II Asst Mgr
_______ % All Prem Growth _______ % Fid VIP High Inc
_______ % Fid Growth Opps _______ % Sel Inv Gr Inc
_______ % AIM V.I. Value _______ % All Gov Bond
_______ % DGPF Grwth Opps _______ % All MM
_______ % Kemper Tech Gro _______ % Fixed Acc
Guarantee Period Accounts
_____% 2 Year _____% 5 Year _____% 8 Year
_____% 3 Year _____% 6 Year _____% 9 Year
_____% 4 Year _____% 7 Year _____% 10 Year
100 % (All allocations must total 100%)
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/ / I elect Automatic Account Rebalancing among the above accounts (excluding
Fixed and Guarantee Period Accounts) starting on the 16 th day after issue date
and continuing every:
/ / 1 / / 2 / / 3 / / 6 / / 12 Months
AUTOMATIC ACCOUNT REBALANCING AND DOLLAR COST AVERAGING CANNOT BE IN EFFECT
SIMULTANEOUSLY.
NOTE: If the contract applied for provides for a full refund of the initial
payment under its "Right to Examine" provision, that por-tion of each payment
not allocated to the Fixed Account will be allocated solely to the Money Market
account during its first 15 days. Reallocation will then be made as specified.
11637
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9. TELEPHONE TRANSFER
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I/We authorize and direct Allmerica Financial Life Insurance and Annuity
Company to accept telephone instructions from any person who can furnish proper
identification to effect transfers and future payment allocation changes. I
agree to hold harmless and indemnify Allmerica Financial Life Insurance and
Annuity Company and its affiliates and their collective directors, officers,
employees and agents against any claim arising from such action. / / I DO NOT
accept this telephone transfer privilege.
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10 DOLLAR COST AVERAGING
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Please transfer $______________ from (check ONE source account):
($100 minimum)
/ / Fixed Account / / Government Bond / / Money Market
Every / / 1 / / 2 / / 3 / / 6 / / 12 Months
_______ % Pio Emerg Mkt _______ % Invesco Hlth Sc
_______ % Sel Emg Mkt _______ % KVS Fin'l Scvs
_______ % All Sel Int'l Eq _______ % Frkln Nat Rsrcs
_______ % DGPF Int'l Eq _______ % All Sel Gro
_______ % Fid VIP Overseas _______ % Core Equity
_______ % T. R Pr Int'l Stk _______ % Fid VIP Gro
_______ % AIM Aggr Growth _______ % Janus Gro & Inc
_______ % Frkln Small Cap _______ % Alliance Gro & Inc
_______ % Sel Strat Gro _______ % Pio Real Estate
_______ % All Sel Aggr Gro _______ % All Eq Index
_______ % All Sel Cap App _______ % All Sel Gro & Inc
_______ % All Sel Val Opp _______ % Fid VIP Eq-Inc
_______ % Janus Aspen Gro _______ % Fid VIP II Asst Mgr
_______ % All Prem Growth _______ % Fid VIP High Inc
_______ % Fid Growth Opps _______ % Sel Inv Gr Inc
_______ % AIM V.I. Value _______ % All Gov Bond
_______ % DGPF Grwth Opps _______ % All MM
_______ % Kemper Tech Gro _______ % Fixed Acc
Dollar Cost Averaging begins on the 16 th day after the issue date and ends
when the source account value is exhausted.
DOLLAR COST AVERAGING INTO THE FIXED OR GUARANTEE PERIOD ACCOUNTS IS NOT
AVAILABLE.
*(WHEN AVAILABLE FILL IN E-DCA FORM.)
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11 SYSTEMATIC WITHDRAWALS
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A VOIDED CHECK MUST BE ATTACHED.
Please withdraw $______________ starting 16 days after
($100 minimum)
issue or ___/___/___, whichever is later, and then
Every / / 1 / / 2 / / 3 / / 6 / / 12 Months
Program (Please choose one):
1. / / Systematic Withdrawal without surrender charge
/ / Maximum (10% of payment)
/ / $_______________ per frequency
OR
2. / / Systematic Withdrawal (May incur surrender charges)
$_______________ per frequency
__________% From _____________________________________
__________% From _____________________________________
__________% From _____________________________________
__________% From _____________________________________
__________% From _____________________________________
100
----------%
(Systematic withdrawals from the Guarantee Period Accounts are not available.)
PLEASE / / Do Not Withhold Federal Income Taxes
/ / Do Withhold at 10% or _______________ (% or $)
/ / 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.
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12 OPTIONAL BILLING REMINDERS
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/ / I wish to receive periodic reminders that I can include with future
remittances.
PAYMENT REMINDER REQUEST (FORM SML-1203) MUST BE ATTACHED.
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13 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 RESIDENTS ONLY: "Any
person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance or state-ment 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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14 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. 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 ARE SUBJECT TO A MARKET VALUE ADJUSTMENT FORMULA, THE
OPERATION OF WHICH MAY RESULT IN EITHER AN UPWARD OR DOWNWARD ADJUSTMENT. I/We
understand that unless I/we elect otherwise, the Annuity Date will be the
earlier of the date, if any, selected by the Owner, or the later of the Owner's
99th birthday or the birthday following the tenth contract anniversary, not to
exceed age 99.
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Signature of Owner Signed at (City and State) Date
--------------------------------- THIS VARIABLE LIFE POLICY IS NOT: A BANK
Signature of Joint Owner DEPOSIT OR OBLIGATION; FEDERALLY INSURED;
ENDORSED BY ANY BANK OR GOVERNMENT AGENCY.
[NO BANK LOGO] [NO FDIC LOGO]
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15 REGISTERED REPRESENTATIVE INFORMATION
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Does the contract applied for replace an existing annuity or life insurance
policy?
/ / Yes / / No If yes, attach replacement forms as required.
I CERTIFY THAT (1) THE INFORMATION PROVIDED BY THE OWNER HAS BEEN ACCURATELY
RECORDED; (2) A CURRENT PROSPECTUS WAS DELIVERED; (3) NO WRITTEN SALES
MATERIALS OTHER THAN THOSE APPROVED BY THE PRINCIPAL OFFICE WERE USED; AND (4)
I HAVE REASONABLE GROUNDS TO BELIEVE THE PURCHASE OF THE CONTRACT APPLIED FOR
IS SUITABLE FOR THE OWNER.
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Date Signature of Registered Representative % TR Print Full Name SS# FL Lic# Code Agency
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Date Signature of Registered Representative % TR Print Full Name SS# FL Lic# Code Agency
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Date Signature of Registered Representative % TR Print Full Name SS# FL Lic# Code Agency
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