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[LOGO] ALLMERICA FINANCIAL LIFE INSURANCE AND ANNUITY COMPANY
VARIABLE ANNUITY APPLICATION 440 LINCOLN STREET, WORCESTER, MA 01653
PLEASE PRINT CLEARLY
1 OWNER
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First Name, Middle Initial, Last Name Social Security Number
/ /
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Address Date of Birth/Trust
/ / Male / / Female / / Trust
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City, State, Zip
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2 JOINT OWNER (If any)
/ / / / Male / / Female
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Name Social Security Number Date of Birth
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3 ANNUITANT (Complete only if different from the Owner in Section 1)
/ / / / Male / / Female
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Name Social Security Number Date of Birth
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4 JOINT ANNUITANT (If any)
/ / / / Male / / Female
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Name Social Security Number Date of Birth
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5 BENEFICIARY(IES) For Joint Owners, surviving Owner is always Primary
beneficiary. If beneficiary is a trust, provide date of trust.
Primary
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Name Relationship to Owner
Contingent
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Name Relationship to Owner
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6 TYPE OF PLAN *Additional forms required
/ / Nonqualified / / IRA TAX YEAR _____ / / Roth IRA TAX YEAR _____
/ / Nonqualified Deferred / / IRA Rollover / / Roth IRA
Comp. Rollover/Conversion
/ / 457 Deferred / / IRA Transfer / / SEP-IRA* TAX YEAR _____
Compensation*
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7 ALLOCATION OF PURCHASE PAYMENTS Make check payable to Allmerica Financial
Please allocate my purchase payment of $____________ as follows:
_____% Emerging Markets _____% Growth Shares
_____% Balanced _____% Money Market
_____% International Growth _____% Real Estate Growth
_____% Swiss Franc Bond _____% ____________
_____% Europe _____% Growth and Income
_____% Strategic Income _____% Fixed Account
_____% Capital Growth _____% Equity-Income
_____% America Income
Guarantee Period Accounts (GPAs) ($1,000 min.) Not available in Maryland,
Oregon, Pennsylvania or Washington.
_____% 2 Year _____% 5 Year _____% 8 Year
_____% 3 Year _____% 6 Year _____% 9 Year
_____% 4 Year _____% 7 Year _____% 10 Year
ALL ALLOCATIONS ABOVE (TO VARIABLE, FIXED AND GUARANTEE PERIOD ACCOUNTS) MUST
TOTAL 100%.
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/ / I elect the BUILD WITH INTEREST & GROWTH (BIG) PLAN. Allocate part of my
purchase payment to the ____ year GPA such that, at the end of the Guarantee
Period, the GPA value is equal to my purchase payment. The remaining balance
will be allocated as indicated above.
/ / I elect AUTOMATIC ACCOUNT REBALANCING (AAR) among the above variable
accounts: / / Monthly / / Quarterly / / Semi-annually / / Annually
/ / I elect DOLLAR COST AVERAGING (DCA) (not available with AAR) from:
/ / Fixed Account / / America Income / / Money Market
$____________ Total amount per transfer / / Monthly / / Quarterly
/ / Semi-annually / / Annually
Percent or Dollar amount Transferred to (write in variable account name)
----------% $ --------- ------------------
----------% $ --------- ------------------
----------% $ --------- ------------------ DCA into the Fixed or
----------% $ --------- ------------------ Guarantee Period Accounts
----------% $ --------- ------------------ is not available.
SML-1517 (1/00) 0399-6385
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8 OPTIONAL RIDERS
/ / Enhanced Death Benefit
/ /
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9 REPLACEMENT
Will the proposed contract replace or change any existing annuity or life
insurance policy?
/ / No / / Yes (if yes, list company name and policy number)_____________
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10 TELEPHONE AUTHORIZATION
I/We authorize and direct Allmerica Financial to accept telephone instructions
from any person who can furnish proper identification to effect transfers,
future payment allocation changes and obtain values. Neither Allmerica Financial
nor its affiliates and their collective directors, officers, employee and agents
will be responsible for any claim arising from such action if Allmerica
Financial acted on instructions in good faith and in reliance on this
authorization.
/ / I/WE DO NOT accept this telephone privilege.
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11 SYSTEMATIC WITHDRAWALS Not available from Guarantee Period Accounts.
Begin withdrawals: later of 15 days after issue or / /
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Amount: / / _______% of purchase payment
/ / $_______ per frequency
Frequency: / / Monthly / / Quarterly / / Semi-annually / / Annually
Withdraw: / / Pro rata from all accounts or
________% from ______________________ ________% from ________________
________% from ______________________ ________% from ________________
Tax Withholding: / / Do NOT Withhold Federal Income Taxes
/ / Do Withhold at 10% or __________ (% or $)
Direct Deposit: / / Check here for Electronic Funds Transfer (Direct Deposit).
I authorize the Company to correct electronically any
overpayments or erroneous credits made to my account.
ATTACH A VOIDED CHECK.
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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 any false, incomplete or
misleading information is guilty of a felony of the third degree."
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13 SIGNATURES
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 Buyers 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 ARE
SUBJECT TO A MARKET VALUE ADJUSTMENT FORMULA (IF APPLICABLE), THE OPERATION OF
WHICH MAY RESULT IN EITHER AN UPWARD OR DOWNWARD ADJUSTMENT.
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Signature of Owner Signature of Joint Owner
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Signed at (City and State) Date
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14 REGISTERED REPRESENTATIVE/DEALER INFORMATION
Does the contract 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(s) 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 contract applied for is suitable for the
owner(s).
( )
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Signature of Registered Social Security# TR Code Telephone
Representative FL LIC #
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Printed Name of Registered B/D Client Account # Printed Name of Broker/Dealer
Representative
( )
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Branch office Street Address for Contract Delivery Telephone
SML-1517 (1/00) 0399-6385
