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PIONEER NO-LOAD FIRST ALLMERICA FINANCIAL LIFE INSURANCE AND ANNUITY COMPANY
VARIABLE ANNUITY APPLICATION 440 LINCOLN STREET, WORCESTER, MA 01653
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
City, State, Zip
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2 JOINT OWNER (If any)
/ /
---------------------------------- ------------------------ ------------- / / Male / / Female
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
Name Social Security Number Date of Birth
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4 JOINT ANNUITANT (If any)
/ /
---------------------------------- ------------------------ ------------- / / Male / / Female
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 Comp. / / IRA Rollover / / Roth IRA Rollover/Conversion
/ / 457 Deferred Comp* / / IRA Transfer / / SEP-IRA* TAX YEAR _____
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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
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/ / 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
_______% $ ___________ ______________________________________________ Account is not
_______% $ ___________ ______________________________________________ available.
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8 OPTIONAL RIDERS
/ / Enhanced Death Benefit
/ / _______________________________________________________________________
SML-1517NY (1/00)
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9 REPLACEMENT
Will the proposed certificate 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 SYSTEMATIC WITHDRAWALS Not available from Guarantee Period Accounts.
Begin withdrawals: later of 15 days after issue or ___________
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 Withhoold 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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11 REMARKS
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12 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 certificate are those contained in this application. I/We acknowledge receipt of a current
prospectus describing the certificate 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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13 REGISTERED REPRESENTATIVE/DEALER INFORMATION
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(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 certificate applied
for is suitable for the owner(s).
______
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Signature of Registered Representative Social Security # TR Code Telephone
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Signature of Registered Representative B/D Client Account # Printed Name of Broker/Dealer
( )
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Branch office Street Address for Certificate Delivery Telephone
SML-1517NY (1/00) 0399-6385
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