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DELAWARE MEDALLION FREEDOM FIRST ALLMERICA FINANCIAL LIFE
VARIABLE ANNUITY APPLICATION INSURANCE AND ANNUITY COMPANY
440 Lincoln Street, Worcester, MA 01653
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1. OWNER(S) PLEASE PRINT CLEARLY
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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 / / Male
- - / / / / Female
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Daytime Telephone
( )
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2. ANNUITANT(S) PLEASE PRINT CLEARLY
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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)
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If there are Joint Owners, the survivor is always Primary Beneficiary.
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Primary Beneficiary Relationship to Owner
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Contingent Beneficiary Relationship to Owner
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4. OPTIONAL RIDERS (MAY NOT BE AVAILABLE IN ALL STATES)
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I/We elect: / / Enhanced Death Benefit
/ /________________________________________________________________
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5. TYPE OF PLAN TO BE ISSUED
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/ / Nonqualified Roth / / IRA
/ / Nonqualified Def. Comp. / / SEP-IRA*
/ / IRA / / 457 Def. Comp.*
*Attach required additional forms. Existing Case#____________
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6. INITIAL PAYMENT
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Initial Payment $____________________________________________________________
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
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_____% Growth & Income Series _____% AIM High Yield
_____% Devon Series _____% AIM International
_____% Growth Opportunities Series _____% AIM Value
_____% U.S. Growth Series _____% Alger Lev AllCap
_____% Select Growth _____% Alger MidCap Growth
_____% Social Awareness Series _____% Alger Small Cap
_____% REIT Series _____% Alliance Growth
_____% Small Cap Value Series _____% Alliance Gro & Inc
_____% Trend Series _____% Alliance Prem Growth
_____% International Equity Series _____% Alliance Technology
_____% Emerging Markets Series _____% Franklin Mut Shares
_____% Balanced _____% Franklin Small Cap
_____% Convertible Securities Series _____% Pioneer Emerg Mkts
_____% High Yield _____% Pioneer Mid-Cap Valu
_____% Capital Reserves Series _____% Templeton Growth Sec
_____% Strategic Income Series _____% Templeton Intl Sec
_____% Cash Reserve Series _____% Fixed Account
_____% Global Bond Series _____%
_____% AIM Growth _____%
Guarantee Period Accounts (GPA) ($1,000 minimum per Account)
_____ % 2 Year _____ % 5 Year _____ % 8 Year
_____ % 3 Year _____ % 6 Year _____ % 9 Year
_____ % 4 Year _____ % 7 Year _____ % 10 Year
ALL ALLOCATIONS ABOVE MUST TOTAL 100%.
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8. SECURED PRINCIPAL
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/ / Allocate part of my/our payment to the ________ year GPA such that,
at the end of the Guarantee Period, the GPA value is equal to my/our
payment. The remaining balance will be applied as indicated above.
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9. AUTOMATIC
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/ / I/We elect AUTOMATIC ACCOUNT REBALANCING (AAR) among the above
variable accounts: / / Monthly / / Quarterly / / Semi-annually / / Annually
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10. DOLLAR COST AVERAGING
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(NOT AVAILABLE WITH AUTOMATIC ACCOUNT REBALANCING.)
Please transfer $____________ (check ONE source account):
($100 minimum)
(Be sure to allocate money to this source account in Section 7.)
FROM: / / Fixed Account / / Capital Reserves
/ / Cash Reserve / / Strategic Income
/ / Monthly / / Quarterly / / Semi-annually / / Annually
TO: (Check one)/ / $ or / / %
_____Growth & Income Series _____AIM High Yield
_____Devon Series _____AIM International
_____Growth Opportunities Series _____AIM Value
_____U.S. Growth Series _____Alger Lev AllCap
_____Select Growth _____Alger MidCap Growth
_____Social Awareness Series _____Alger Small Cap
_____REIT Series _____Alliance Growth
_____Small Cap Value Series _____Alliance Gro & Inc
_____Trend Series _____Alliance Prem Growth
_____International Equity Series _____Alliance Technology
_____Emerging Markets Series _____Franklin Mut Shares
_____Balanced _____Franklin Small Cap
_____Convertible Securities Series _____Pioneer Emerg Mkts
_____High Yield _____Pioneer Mid-Cap Valu
_____Capital Reserve Series _____Templeton Growth Sec
_____Strategic Income Series _____Templeton Intl Sec
_____Cash Reserve Series _____
_____Global Bond Series _____
_____AIM Growth
DCA INTO THE FIXED OR GUARANTEE PERIOD ACCOUNTS IS NOT AVAILABLE.
11255DGNY (5/00) GDM-APPG
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10. REPLACEMENT
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Will the proposed contract replace or change any existing annuity or
insurance policy? / / Yes / / No
(If yes, list company name and policy number.) _______________________
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________________________________________________________________
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11. REMARKS
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______________________________________________________
______________________________________________________
______________________________________________________
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12. SYSTEMATIC WITHDRAWALS ($100 MINIMUM)
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A. Frequency (Please choose one):
/ / Monthly / / Quarterly / / Semi-annually / / Annually
Withdrawals begin later of 15 days after issue or ____/____/____.
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B. Amount:
1. / / ________% of purchase payment
/ /$________ per frequency
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C. Withdraw from:
/ / 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
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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
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.
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Signature of Owner Date Signature of Joint Owner Date
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Signed at (City and State)
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14. REGISTERED REPRESENTATIVE / DEALER INFORMATION
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DOES THE CERTIFICATE APPLIED FOR REPLACE AN EXISTING ANNUITY OR LIFE INSURANCE
POLICY? / / YES (ATTACH REPLACEMENT FORMS AS 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 certificate applied for is suitable for
the owner.
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- - / / ( )
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Signature of Registered Representative SSN# TR Code Telephone
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Printed Name of Registered Representative
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Printed Name of Broker/Dealer B/D Client Acct. #
( )
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Branch Office Street Address for Contract Delivery Telephone
11255DGNY (5/00) GDM-APPG
