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[LOGO] FIRST ALLMERICA FINANCIAL LIFE INSURANCE COMPANY
440 LINCOLN STREET WORCESTER, MA 01653
VARIABLE ANNUITY APPLICATION [ALLMERICA SELECT REWARD]
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1 MY INVESTMENT How much I want to invest.
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I am investing $________________ in Allmerica Select Reward.
(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
_____ % Alliance Premier Growth
_____ % Select Strategic Gr.
_____ % Fidelity VIP Growth
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.
_____ % Alliance Premier _____ % Allmerica Money Mkt.
_____ % Growth 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 (May not be available in all states)
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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-563NY
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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*
/ / Pension/Profit Sharing (401(a))*
/ / Profit Sharing (401(k))*
/ / Tax-Sheltered Annuity Plan (Section 403(b))*
/ / Deferred Compensation Plan (Section 457)*
*Attach required additional forms. Existing Case # ______________
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11 REMARKS
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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 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.
X
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Signature of Registered Representative Print Name of Registered Representative Telephone
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TR Code 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
ALLMERICA SELECT - FIRST ALLMERICA FINANCIAL LIFE INSURANCE COMPANY
440 LINCOLN STREET - WORCESTER, MA 01653
AS-563NY
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