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PIONEER XTRAVISION FIRST ALLMERICA FINANCIAL LIFE INSURANCE 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
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 / / 401(k) Profit Sharing* / / IRA Rollover / / Roth IRA Rollover/Conversion
/ / Nonqualified Deferred Comp. / / 403(b) TSA* / / IRA Transfer / / SEP-IRA* TAX YEAR _____
/ / 401(a) Pension/Profit Sharing* / / IRA TAX YEAR _____ / / Roth 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 _____% ____________
_____% Capital Growth _____% Equity-Income _____% America Income _____% Fixed Account
ALL ALLOCATIONS ABOVE (TO VARIABLE AND FIXED ACCOUNT) MUST TOTAL 100%.
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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
Amount per transfer Transfer to (write in variable account name)
$ ___________ _______________________________________ DCA into the Fixed Account is not available.
$ ___________ _______________________________________
$ ___________ _______________________________________
$ ___________ _______________________________________
$ ___________ Total amount per transfer / / Monthly / /Quarterly / /Semi-annually / / Annually
SML-1468P NY
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8 OPTIONAL RIDERS
/ / Enhanced Death Benefit
/ / ____________________________________________________________________________
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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
Begin withdrawals: later of 15 days after issue or _____/______/_______
Amount: / / _______% of purchase payment (maximum 15% without surrender charge)
/ / $______ per frequency / / Check here if you do not wish to exceed the maximum available without
surrender charge
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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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.
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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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Printed Name of Registered Representative B/D Client Account # Printed Name of Broker/Dealer
( )
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Branch office Street Address for Contract Delivery Telephone
SML-1468P NY
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