Common use of RIGHT TO EXAMINE CONTRACT Clause in Contracts

RIGHT TO EXAMINE CONTRACT. The Owner may cancel this contract by returning it to the Company or one of its authorized representatives within ten days after receipt. If returned, the Company will refund an amount equal to the Accumulated Value, after application of any Market Value Adjustment, plus any fees or other charges imposed. If, however, the contract is issued as an Individual Retirement Annuity (IRA), the Company will refund the greater of the above or the gross payments. ALLMERICA FINANCIAL LIFE INSURANCE AND ANNUITY COMPANY Home Office: Dover, Delaware Principal Office: 000 Xxxxxxx Xxxxxx, Xxxxxxxxx, Xxxxxxxxxxxxx 00000 This is a legal contract between Allmerica Financial Life Insurance and Annuity Company (the Company) and the Owner and is issued in consideration of the Initial Payment shown on the Specifications page. Additional Payments are permitted. Payments may be allocated to Variable Sub-Accounts, the Fixed Account or Guarantee Period Accounts. While this contract is in effect, the Company agrees to pay annuity benefit payments beginning on the Annuity Date or to pay a Death Benefit to the Beneficiary if an Owner dies prior to the Annuity Date. President Secretary Flexible Payment Deferred Variable and Fixed Annuity Annuity Benefit Payments Payable on the Annuity Date Death Benefit Payable to Beneficiary if Owner Dies prior to Annuity Date Non-Participating Form A3031-99 TABLE OF CONTENTS SPECIFICATONS DEFINITIONS OWNER, ANNUITANT AND BENEFICIARY THE ACCUMULATION PHASE PAYMENTS VALUES TRANSFER XXXXXXXXXX AND SURRENDER DEATH BENEFIT THE PAYOUT PHASE ANNUITY BENEFIT TRANSFER WITHDRAWAL PRESENT VALUE OF ANNUITY BENEFIT PAYMENTS DEATH OF THE ANNUITANT ANNUITY BENEFIT PAYMENT OPTIONS ANNUITY BENEFIT PAYMENT GUARANTEE OPTIONS ANNUITY OPTION TABLES GENERAL PROVISIONS Form A3031-99

RIGHT TO EXAMINE CONTRACT. The Owner Within 10 days of the date of receipt of this Contract by the Owner, it may cancel this contract be returned by returning delivering or mailing it to the Company or one of at its authorized representatives within ten days after receiptAnnuity Service Center. If returnedWhen this Contract is received by the Company, it will be voided as if it had never been in force. A written request for cancellation must accompany the Company will refund an amount equal to the Accumulated Value, after application of any Market Value Adjustment, plus any fees or other charges imposedcontract. If, however, the contract is issued as an Individual Retirement Annuity (IRA)In such event, the Company will refund the greater Contract Value, computed at the end of the above or Valuation Period during which this Contract is received by the gross paymentsCompany at its Annuity Service Center. ALLMERICA FINANCIAL LIFE INSURANCE AND ANNUITY COMPANY Home Office: Dover, Delaware Principal Office: 000 Xxxxxxx Xxxxxx, Xxxxxxxxx, Xxxxxxxxxxxxx 00000 This is a legal contract between Allmerica Financial Life Insurance and Annuity The Company (has reserved the Company) and right to allocate the Owner and is issued in consideration Contribution to the Money Market Sub-Account until the expiration of the Initial Payment shown on the Specifications pageRight to Examine Contract period. Additional Payments are permittedTHIS IS A LEGAL CONTRACT BETWEEN THE OWNER AND THE COMPANY READ YOUR CONTRACT CAREFULLY George C. Nicholson, Ian K. Whitehead, SECRETARY PRESIDENT INDIVIDUAL VARIABLE SINGLE CONTRIBUTION IMMEDIATE ANNUITY CONTRACT NONPARTICIPATING ANNUITY PAYMENTS PROVIDED BY THIS CONTRACT ARE BASED ON THE INVESTMENT EXPERIENCE OF A SUB-ACCOUNT AND WILL VARY IN ACCORDANCE WITH THE PERFORMANCE OF THE SUB-ACCOUNT. Payments may be allocated to Variable Sub-Accounts, the Fixed DETAILS OF THE VARIABLE PROVISIONS ARE DESCRIBED UNDER VALUATION PROVISIONS ON PAGE ____. {policy #} TABLE OF CONTENTS PAGE CONTRACT SCHEDULE DEFINITIONS CONTRIBUTION PROVISIONS Contribution Allocation of Contribution SEPARATE ACCOUNT PROVISIONS The Separate Account or Guarantee Period Accounts. While this contract is in effect, the Company agrees to pay annuity benefit payments beginning on Separate Account Charge Valuation of Assets VALUATION PROVISIONS Accumulation Units Accumulation Unit Value Annuity Unit Value Net Investment Factor CONTRACT VALUE TRANSFERS Transfers Before the Annuity Date or to pay a Death Benefit to the Beneficiary if an Owner dies prior to the Annuity Date. President Secretary Flexible Payment Deferred Variable and Fixed Annuity Annuity Benefit Payments Payable on Transfers After the Annuity Date Death Benefit Payable to Beneficiary if Owner Dies prior to ANNUITY PROVISIONS Annuity Date Non-Participating Form A3031-99 TABLE Determination of Annuity Payments Frequency and Amount of Annuity Payments SUSPENSION OR DEFERRAL OF CONTENTS SPECIFICATONS DEFINITIONS PAYMENT PROVISIONS OWNER, ANNUITANT AND BENEFICIARY THE ACCUMULATION PHASE PAYMENTS VALUES TRANSFER XXXXXXXXXX AND SURRENDER DEATH BENEFIT THE PAYOUT PHASE ANNUITY BENEFIT TRANSFER WITHDRAWAL PRESENT VALUE OF ANNUITY BENEFIT PAYMENTS DEATH OF THE ANNUITANT ANNUITY BENEFIT PAYMENT OPTIONS ANNUITY BENEFIT PAYMENT GUARANTEE OPTIONS ANNUITY OPTION TABLES GENERAL ANNUITANT, OWNERSHIP, ASSIGNMENT PROVISIONS Form A3031-99Owner Annuitant Assignment Of The Contract

RIGHT TO EXAMINE CONTRACT. The Owner Within 10 days of the date of receipt of this Contract by the Owner, it may cancel this contract be returned by returning delivering or mailing it to the Company or one of at its authorized representatives within ten days after receiptAnnuity Service Center. If returnedWhen the Contract is received by the Company, the Company it will refund an amount equal to the Accumulated Value, after application of any Market Value Adjustment, plus any fees or other charges imposedbe voided as if it has never been in force. If, however, the contract is issued as an Individual Retirement Annuity (IRA), the The Company will refund the greater Contract Value, computed at the end of the above or the gross payments. ALLMERICA FINANCIAL LIFE INSURANCE AND ANNUITY COMPANY Home Office: Dover, Delaware Principal Office: 000 Xxxxxxx Xxxxxx, Xxxxxxxxx, Xxxxxxxxxxxxx 00000 This Valuation Period during which this Contract is a legal contract between Allmerica Financial Life Insurance and Annuity Company (the Company) and the Owner and is issued in consideration of the Initial Payment shown on the Specifications page. Additional Payments are permitted. Payments may be allocated to Variable Sub-Accounts, the Fixed Account or Guarantee Period Accounts. While this contract is in effect, received by the Company agrees to pay annuity benefit payments beginning on the at its Annuity Date or to pay a Death Benefit to the Beneficiary if an Owner dies prior to the Annuity DateService Center. THIS IS A LEGAL CONTRACT BETWEEN THE OWNER AND THE COMPANY READ YOUR CONTRACT CAREFULLY George C. Nicholson, Xxx X. Whitehead, Secrexxxx President Secretary Flexible Payment Deferred Variable and Fixed Annuity Annuity Benefit Payments Payable on the Annuity Date Death Benefit Payable to Beneficiary if Owner Dies prior to Annuity Date Non-Participating Form A3031-99 INDIVIDUAL FIXED AND VARIABLE DEFERRED ANNUITY CONTRACT WITH FLEXIBLE CONTRIBUTIONS NONPARTICIPATING ANNUITY PAYMENTS, WITHDRAWAL VALUES AND THE DEATH BENEFITS PROVIDED BY THIS CONTRACT, WHEN BASED ON THE INVESTMENT EXPERIENCE OF THE SEPARATE ACCOUNT, ARE VARIABLE AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT. TABLE OF CONTENTS SPECIFICATONS PAGE CONTRACT SCHEDULE DEFINITIONS OWNER, ANNUITANT AND BENEFICIARY THE ACCUMULATION PHASE PAYMENTS VALUES TRANSFER XXXXXXXXXX AND SURRENDER DEATH BENEFIT THE PAYOUT PHASE ANNUITY BENEFIT TRANSFER CONTRIBUTION PROVISIONS Contributions Allocation Of Contributions SEPARATE ACCOUNT PROVISIONS The Separate Account Valuation Of Assets Accumulation Units Accumulation Unit Value Mortality And Expense Risk Charge Distribution Charge Enhanced Death Benefit Charge FIXED ACCOUNT Fixed Account CONTRACT VALUE CONTRACT MAINTENANCE CHARGE Deduction For Contract Maintenance Charge TRANSFERS Transfers During The Accumulation Period Transfers During The Annuity Period WITHDRAWAL PRESENT VALUE OF ANNUITY BENEFIT PAYMENTS DEATH OF THE ANNUITANT ANNUITY BENEFIT PAYMENT OPTIONS ANNUITY BENEFIT PAYMENT GUARANTEE OPTIONS ANNUITY OPTION TABLES GENERAL PROVISIONS Form A3031-99Withdrawals Contingent Deferred Sales Charge

RIGHT TO EXAMINE CONTRACT. The Owner Within 10 days of the date of receipt of this Contract by the Owner, it may cancel this contract be returned by returning delivering or mailing it to the Company or one of at its authorized representatives within ten days after receiptAdministrative Office. If returnedWhen the Contract is received by the Company, the Company it will refund an amount equal to the Accumulated Value, after application of any Market Value Adjustment, plus any fees or other charges imposedbe voided as if it had never been in force. If, however, the contract is issued as an Individual Retirement Annuity (IRA), the The Company will refund the greater Contract Value computed at the end of the above or Valuation Period during which the gross payments. ALLMERICA FINANCIAL LIFE INSURANCE AND ANNUITY COMPANY Home Office: Dover, Delaware Principal Office: 000 Xxxxxxx Xxxxxx, Xxxxxxxxx, Xxxxxxxxxxxxx 00000 This Contract is a legal contract between Allmerica Financial Life Insurance and Annuity Company (the Company) and the Owner and is issued in consideration of the Initial Payment shown on the Specifications page. Additional Payments are permitted. Payments may be allocated to Variable Sub-Accounts, the Fixed Account or Guarantee Period Accounts. While this contract is in effect, received by the Company agrees to pay annuity benefit payments beginning on the Annuity Date or to pay a Death Benefit to the Beneficiary if an Owner dies prior to the Annuity Dateat its Administrative Office. President Secretary Flexible Payment Deferred Variable and Fixed Annuity Annuity Benefit Payments Payable on the Annuity Date Death Benefit Payable to Beneficiary if Owner Dies prior to Annuity Date THIS IS A LEGAL CONTRACT BETWEEN THE OWNER AND THE COMPANY READ YOUR CONTRACT CAREFULLY SECRETARY PRESIDENT INDIVIDUAL FIXED AND VARIABLE ANNUITY CONTRACT Non-Participating Form A3031-99 participating WITHDRAWAL VALUES AND THE DEATH BENEFITS PROVIDED BY THIS CONTRACT, WHEN BASED ON THE INVESTMENT EXPERIENCE OF THE VARIABLE ACCOUNT, ARE VARIABLE AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT. NON FORFEITURE VALUES MAY INCREASE OR DECREASE BASED ON THE MARKET VALUE ADJUSTMENT SPECIFIED IN THIS CONTRACT. TABLE OF CONTENTS SPECIFICATONS CONTRACT SCHEDULE DEFINITIONS PURCHASE PAYMENT PROVISIONS PURCHASE PAYMENTS ALLOCATION OF PURCHASE PAYMENTS SEPARATE ACCOUNT PROVISIONS THE SEPARATE ACCOUNTS VARIABLE ACCOUNT VALUATION OF ASSETS ACCUMULATION UNITS ACCUMULATION UNIT VALUE MORTALITY AND EXPENSE RISK CHARGE ADMINISTRATIVE CHARGE DISTRIBUTION EXPENSE CHARGE MVA ACCOUNT PROVISIONS MVA ACCOUNT INTEREST TO BE CREDITED GUARANTEE PERIOD MULTIPLE GUARANTEE PERIODS CHANGE IN GUARANTEE PERIOD MARKET VALUE ADJUSTMENT MVA ACCOUNT VALUES FIXED ACCOUNT PROVISIONS FIXED ACCOUNT VALUES INTEREST TO BE CREDITED CONTRACT VALUE CONTRACT MAINTENANCE CHARGE DEDUCTION FOR CONTRACT MAINTENANCE CHARGE TRANSFERS TRANSFERS DURING THE ACCUMULATION PERIOD TRANSFERS DURING THE ANNUITY PERIOD WITHDRAWAL PROVISIONS WITHDRAWALS CONTINGENT DEFERRED SALES CHARGE WITHDRAWAL CHARGE PROCEEDS PAYABLE ON DEATH DEATH OF OWNER DURING THE ACCUMULATION PERIOD DEATH BENEFIT AMOUNT DURING THE ACCUMULATION PERIOD DEATH BENEFIT OPTIONS DURING THE ACCUMULATION PERIOD DEATH OF OWNER DURING THE ANNUITY PERIOD DEATH OF ANNUITANT PAYMENT OF DEATH BENEFIT BENEFICIARY CHANGE OF BENEFICIARY SUSPENSION OR DEFERRAL OF PAYMENTS PROVISION OWNER, ANNUITANT, OWNERSHIP, ASSIGNMENT PROVISIONS OWNER JOINT OWNER ANNUITANT ASSIGNMENT OF A CONTRACT ANNUITY PROVISIONS GENERAL ANNUITY DATE SELECTION OF AN ANNUITY OPTION FREQUENCY AND BENEFICIARY THE ACCUMULATION PHASE PAYMENTS VALUES TRANSFER XXXXXXXXXX AND SURRENDER DEATH BENEFIT THE PAYOUT PHASE ANNUITY BENEFIT TRANSFER WITHDRAWAL PRESENT VALUE AMOUNT OF ANNUITY BENEFIT PAYMENTS DEATH OF THE ANNUITANT ANNUITY BENEFIT PAYMENT OPTIONS OPTION 1. LIFETIME ONLY ANNUITY: OPTION 2. LIFETIME ANNUITY BENEFIT PAYMENT GUARANTEE OPTIONS WITH GUARANTEED PERIODS OPTION 3. INSTALLMENT REFUND LIFE ANNUITY OPTION 4. PAYMENT FOR A FIXED PERIOD: OPTION 5. JOINT AND SURVIVOR ANNUITY ANNUITY FIXED ANNUITY VARIABLE ANNUITY ANNUITY UNIT MORTALITY TABLES GENERAL PROVISIONS Form A3031THE CONTRACT MISSTATEMENT OF AGE INCONTESTABILITY MODIFICATION NON-99PARTICIPATING EVIDENCE OF SURVIVAL PROOF OF AGE PROTECTION OF PROCEEDS REPORTS TAXES REGULATORY REQUIREMENTS CONTRACT SCHEDULE OWNER: [John Doe] CONTRACT NUMBER: [10000] CONTRACT ISSUE DATE:[January 3, 1995] ANNUITY DATE: [January 3, 2000] PURCHASE PAYMENTS: INITIAL PURCHASE PAYMENT: [$50,000 Non-Qual; $10,000 IRA - 403(b) rollover] MINIMXX SUBSEQUENT PURCHASE PAYMENT: [$1,000; or if the automatic premium check option is elected: $250 monthly] MAXIMUM TOTAL PURCHASE PAYMENT: [$1,000,000, without prior Company approval]

RIGHT TO EXAMINE CONTRACT. The Owner may cancel this contract by returning it to the Company or one of its authorized representatives within ten days after receipt. If returned, the Company will refund an amount equal to the Accumulated Value, after application of any Market Value Adjustment, plus any fees or other charges imposed. If, however, the contract is issued as an Individual Retirement Annuity (IRA), the Company will refund the greater of the above or the gross payments. ALLMERICA FINANCIAL LIFE INSURANCE AND ANNUITY COMPANY Home Office: Dover, Delaware Principal Office: 000 Xxxxxxx Xxxxxx, Xxxxxxxxx, Xxxxxxxxxxxxx 00000 This is a legal contract between Allmerica Financial Life Insurance and Annuity Company (the Company) and the Owner and is issued in consideration of the Initial Payment shown on the Specifications page. Additional Payments are permitted. Payments may be allocated to Variable Sub-Accounts, the Fixed Account or Guarantee Period Accounts. While this contract is in effect, the Company agrees to pay annuity benefit payments beginning on the Annuity Date or to pay a Death Benefit to the Beneficiary if an Owner dies prior to the Annuity Date. President Secretary Flexible Payment Deferred Variable and Fixed Annuity Annuity Benefit Payments Payable on the Annuity Date Death Benefit Payable to Beneficiary if Owner Dies prior to Annuity Date Non-Participating Form A3031A3030-99 1 TABLE OF CONTENTS SPECIFICATONS DEFINITIONS OWNER, ANNUITANT AND BENEFICIARY THE ACCUMULATION PHASE PAYMENTS VALUES TRANSFER XXXXXXXXXX AND SURRENDER DEATH BENEFIT THE PAYOUT PHASE ANNUITY BENEFIT TRANSFER WITHDRAWAL PRESENT VALUE OF ANNUITY BENEFIT PAYMENTS DEATH OF THE ANNUITANT ANNUITY BENEFIT PAYMENT OPTIONS ANNUITY BENEFIT PAYMENT GUARANTEE OPTIONS ANNUITY OPTION TABLES GENERAL PROVISIONS Form A3031-99DEFINITIONS Accumulated Value The aggregate value of all accounts in this contract before the Annuity Date. As long as the Accumulated Value is greater than zero, the contract will stay in effect.

RIGHT TO EXAMINE CONTRACT. The Owner may cancel Within 10 days after this contract is first received (60 days after its receipt for a contract issued in replacement of another contract), it may be cancelled for any reason without penalty (e.g., no withdrawal charges will be deducted) by returning delivering or mailing it to the Company or one of its authorized representatives within ten days after receiptour Servicing Office. If returnedUpon cancellation, the Company will refund an amount equal return any premium payments paid under the Fixed Account of the contract and/or the value of any payments made to the Accumulated Value, after application of any Market Value Adjustment, plus any fees or other charges imposed. If, however, Variable Account on the appropriate Valuation Date as follows: if the contract is issued as an Individual Retirement Annuity (IRA)personally delivered to the Company's Servicing Office or authorized representative, such Valuation Date will be the Company date of delivery. If the contract is mailed to the Company's Servicing Office, such Valuation Date will refund be the greater date the contract is mailed. The contract is governed by the laws of the above or the gross payments. ALLMERICA FINANCIAL LIFE INSURANCE AND ANNUITY COMPANY Home Office: Dover, Delaware Principal Office: 000 Xxxxxxx Xxxxxx, Xxxxxxxxx, Xxxxxxxxxxxxx 00000 This is a legal contract between Allmerica Financial Life Insurance and Annuity Company (the Company) and the Owner and State of New York; it is issued in and accepted subject to the terms set forth on this page and on the following pages which are made a part of this contract. In consideration of the Initial Payment shown on application for it, and the Specifications page. Additional Payments are permitted. Payments may be allocated to Variable Sub-Accounts, the Fixed Account or Guarantee Period Accounts. While Premium Payment(s) as provided this contract is in effect, executed by the Company agrees to pay annuity benefit payments beginning on the Annuity as of its Date or to pay a Death Benefit to the Beneficiary if an Owner dies prior to the Annuity Dateof Issue. President Secretary Flexible Payment Deferred Variable and Fixed Annuity Annuity Benefit Payments Payable on the Annuity Date Death Benefit Payable to Beneficiary if Owner Dies prior to Annuity Date Non-Participating Form A3031-99 TABLE /s/ Xxxxxx X. Xxxxxxx PRESIDENT PAYMENTS AND VALUES BASED ON THE FIXED ACCOUNT ARE SUBJECT TO A MARKET VALUE ADJUSTMENT FORMULA, THE OPERATION OF CONTENTS SPECIFICATONS DEFINITIONS WHICH MAY RESULT IN UPWARD OR DOWNWARD ADJUSTMENTS IN AMOUNTS PAYABLE TO THE OWNER, ANNUITANT INCLUDING WITHDRAWALS AND BENEFICIARY TRANSFERS. PAYMENTS MADE FROM THE ACCUMULATION PHASE FIXED ACCOUNT PURSUANT TO AN ELECTION WHICH BECOMES EFFECTIVE AT THE END OF A GUARANTEED PERIOD AND PAYMENTS MADE UNDER THE "ANNUITY BENEFIT" PROVISIONS AND UNDER THE "PENALTY-FREE ANNUITIZATION" PROVISION ARE NOT SUBJECT TO THE MARKET VALUE ADJUSTMENT. PAYMENTS MADE UNDER THE "DEATH BENEFIT" PROVISIONS ARE NOT SUBJECT TO ANY MARKET VALUE ADJUSTMENT. ALL PAYMENTS AND VALUES TRANSFER XXXXXXXXXX AND SURRENDER DEATH BENEFIT THE PAYOUT PHASE ANNUITY BENEFIT TRANSFER WITHDRAWAL PRESENT VALUE OF ANNUITY BENEFIT PAYMENTS DEATH PROVIDED BY THIS CONTRACT WHEN BASED ON INVESTMENT EXPERIENCE OF THE ANNUITANT VARIABLE ACCOUNT ARE VARIABLE AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT. WITH THE CONTRACT ASSET CHARGES OF 1.40%, THE SMALLEST ANNUAL RATE OF INVESTMENT RETURN WHICH WOULD HAVE TO BE EARNED ON THE ASSETS OF THE SEPARATE ACCOUNT SO THAT THE DOLLAR AMOUNT OF VARIABLE ANNUITY BENEFIT PAYMENT OPTIONS ANNUITY BENEFIT PAYMENT GUARANTEE OPTIONS ANNUITY OPTION TABLES GENERAL PROVISIONS Form A3031-99PAYMENTS WILL NOT DECREASE IS 5.40%.

RIGHT TO EXAMINE CONTRACT. The Owner Within 10 days of the date of receipt of this Contract by the Owner, it may cancel this contract be returned by returning delivering or mailing it to the Company or one of at its authorized representatives within ten days after receiptAdministrative Office. If returnedWhen the Contract is received by the Company, the Company it will refund an amount equal to the Accumulated Value, after application of any Market Value Adjustment, plus any fees or other charges imposedbe voided as if it had never been in force. If, however, the contract is issued as an Individual Retirement Annuity (IRA), the The Company will refund the greater Contract Value computed at the end of the above or Valuation Period during which the gross payments. ALLMERICA FINANCIAL LIFE INSURANCE AND ANNUITY COMPANY Home Office: Dover, Delaware Principal Office: 000 Xxxxxxx Xxxxxx, Xxxxxxxxx, Xxxxxxxxxxxxx 00000 This Contract is a legal contract between Allmerica Financial Life Insurance and Annuity Company (the Company) and the Owner and is issued in consideration of the Initial Payment shown on the Specifications page. Additional Payments are permitted. Payments may be allocated to Variable Sub-Accounts, the Fixed Account or Guarantee Period Accounts. While this contract is in effect, received by the Company agrees to pay annuity benefit payments beginning on the Annuity Date or to pay a Death Benefit to the Beneficiary if an Owner dies prior to the Annuity Dateat its Administrative Office. President Secretary Flexible Payment Deferred Variable and Fixed Annuity Annuity Benefit Payments Payable on the Annuity Date Death Benefit Payable to Beneficiary if Owner Dies prior to Annuity Date THIS IS A LEGAL CONTRACT BETWEEN THE OWNER AND THE COMPANY READ YOUR CONTRACT CAREFULLY SECRETARY PRESIDENT INDIVIDUAL FIXED AND VARIABLE ANNUITY CONTRACT Non-Participating Form A3031-99 participating WITHDRAWAL VALUES AND THE DEATH BENEFITS PROVIDED BY THIS CONTRACT, WHEN BASED ON THE INVESTMENT EXPERIENCE OF THE VARIABLE ACCOUNT, ARE VARIABLE AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT. NON FORFEITURE VALUES MAY INCREASE OR DECREASE BASED ON THE MARKET VALUE ADJUSTMENT SPECIFIED IN THIS CONTRACT. TABLE OF CONTENTS SPECIFICATONS CONTRACT SCHEDULE DEFINITIONS PURCHASE PAYMENT PROVISIONS PURCHASE PAYMENTS ALLOCATION OF PURCHASE PAYMENTS SEPARATE ACCOUNT PROVISIONS THE SEPARATE ACCOUNTS VALUATION OF ASSETS ACCUMULATION UNITS ACCUMULATION UNIT VALUE MORTALITY AND EXPENSE RISK CHARGE ADMINISTRATIVE CHARGE DISTRIBUTION EXPENSE CHARGE MVA ACCOUNT PROVISIONS MVA ACCOUNT INTEREST TO BE CREDITED GUARANTEE PERIOD MULTIPLE GUARANTEE PERIODS CHANGE IN GUARANTEE PERIOD MARKET VALUE ADJUSTMENT MVA ACCOUNT VALUES FIXED ACCOUNT PROVISIONS FIXED ACCOUNT VALUES INTEREST TO BE CREDITED CONTRACT VALUE CONTRACT MAINTENANCE CHARGE DEDUCTION FOR CONTRACT MAINTENANCE CHARGE TRANSFERS TRANSFERS DURING THE ACCUMULATION PERIOD TRANSFERS DURING THE ANNUITY PERIOD WITHDRAWAL PROVISIONS WITHDRAWALS CONTINGENT DEFERRED SALES CHARGE WITHDRAWAL CHARGE PROCEEDS PAYABLE ON DEATH DEATH OF OWNER DURING THE ACCUMULATION PERIOD DEATH BENEFIT AMOUNT DURING THE ACCUMULATION PERIOD DEATH BENEFIT OPTIONS DURING THE ACCUMULATION PERIOD DEATH OF OWNER DURING THE ANNUITY PERIOD DEATH OF ANNUITANT PAYMENT OF DEATH BENEFIT BENEFICIARY CHANGE OF BENEFICIARY SUSPENSION OR DEFERRAL OF PAYMENTS PROVISION OWNER, ANNUITANT, OWNERSHIP, ASSIGNMENT PROVISIONS OWNER JOINT OWNER ANNUITANT ASSIGNMENT OF A CONTRACT ANNUITY PROVISIONS GENERAL ANNUITY DATE SELECTION OF AN ANNUITY OPTION FREQUENCY AND BENEFICIARY THE ACCUMULATION PHASE PAYMENTS VALUES TRANSFER XXXXXXXXXX AND SURRENDER DEATH BENEFIT THE PAYOUT PHASE ANNUITY BENEFIT TRANSFER WITHDRAWAL PRESENT VALUE AMOUNT OF ANNUITY BENEFIT PAYMENTS DEATH OF THE ANNUITANT ANNUITY BENEFIT PAYMENT OPTIONS OPTION 1. LIFETIME ONLY ANNUITY: OPTION 2. LIFETIME ANNUITY BENEFIT PAYMENT GUARANTEE OPTIONS WITH GUARANTEED PERIODS OPTION 3. INSTALLMENT REFUND LIFE ANNUITY OPTION 4. PAYMENT FOR A FIXED PERIOD: OPTION 5. JOINT AND SURVIVOR ANNUITY ANNUITY FIXED ANNUITY VARIABLE ANNUITY ANNUITY UNIT MORTALITY TABLES GENERAL PROVISIONS Form A3031THE CONTRACT MISSTATEMENT OF AGE INCONTESTABILITY MODIFICATION NON-99PARTICIPATING EVIDENCE OF SURVIVAL PROOF OF AGE PROTECTION OF PROCEEDS REPORTS TAXES REGULATORY REQUIREMENTS CONTRACT SCHEDULE OWNER: [John Doe] CONTRACT NUMBER: [10000] CONTRACT ISSUE DATE:[January 3, 1995] ANNUITY DATE: [January 3, 2000] PURCHASE PAYMENTS: INITIAL PURCHASE PAYMENT: [$50,000 Non-Qual; $10,000 IRA - 403(b) rollover] MINIMUM SUBSEQUENT PURCHASE PAYMENT: [$1,000; or if the automatic premium check option is elected: $250 monthly] MAXIMUM TOTAL PURCHASE PAYMENT: [$1,000,000, without prior Company approval]

RIGHT TO EXAMINE CONTRACT. The Owner Within 10 days of the date of receipt of this Contract by the Owner, it may cancel this contract be returned by returning delivering or mailing it to the Company or one of at its authorized representatives within ten days after receiptAnnuity Service Center. If returnedWhen this Contract is received by the Company, it will be voided as if it had never been in force. A written request for cancellation must accompany the Company will refund an amount equal to the Accumulated Value, after application of any Market Value Adjustment, plus any fees or other charges imposedcontract. If, however, the contract is issued as an Individual Retirement Annuity (IRA)In such event, the Company will refund the greater of the above or the gross paymentsContribution THIS IS A LEGAL CONTRACT BETWEEN THE OWNER AND THE COMPANY READ YOUR CONTRACT CAREFULLY George C. Nicholson, Ian K. Whitehead, SECRETARY PRESIDENT INDIVIDUAL FIXED AND VARIABLE SINGLE CONTRIBUTION IMMEDIATE ANNUITY CONTRACT NONPARTICIPATING ANNUITY PAYMENTS PROVIDED BY THIS CONTRACT ARE BASED ON THE INVESTMENT EXPERIENCE OF A SUB-ACCOUNT AND WILL VARY IN ACCORDANCE WITH THE PERFORMANCE OF THE SUB-ACCOUNT, EXCEPT TO THE EXTENT LIMITED BY THE GUARANTEED MINIMUM ANNUITY PAYMENT FEATURE. ALLMERICA FINANCIAL LIFE INSURANCE AND DETAILS OF THE GUARANTEED MINIMUM ANNUITY COMPANY Home Office: Dover, Delaware Principal Office: 000 Xxxxxxx Xxxxxx, Xxxxxxxxx, Xxxxxxxxxxxxx 00000 This is a legal contract between Allmerica Financial Life Insurance and Annuity Company (the Company) and the Owner and is issued in consideration of the Initial Payment shown on the Specifications pagePAYMENT FEATURE ARE DESCRIBED UNDER ANNUITY PROVISIONS ON PAGE ____. Additional Payments are permitted. Payments may be allocated to Variable Sub-Accounts, the Fixed Account or Guarantee Period Accounts. While this contract is in effect, the Company agrees to pay annuity benefit payments beginning on the Annuity Date or to pay a Death Benefit to the Beneficiary if an Owner dies prior to the Annuity Date. President Secretary Flexible Payment Deferred Variable and Fixed Annuity Annuity Benefit Payments Payable on the Annuity Date Death Benefit Payable to Beneficiary if Owner Dies prior to Annuity Date Non-Participating Form A3031-99 {policy #} TABLE OF CONTENTS SPECIFICATONS PAGE CONTRACT SCHEDULE DEFINITIONS CONTRIBUTION PROVISIONS Contribution Allocation of Contribution SEPARATE ACCOUNT PROVISIONS The Separate Account Separate Account Charge Guaranteed Minimum Annuity Payment Charge Valuation of Assets VALUATION PROVISIONS Annuity Unit Value Net Investment Factor ANNUITY PROVISIONS Annuity Date Determination of Annuity Payments Guaranteed Minimum Annuity Payments SUSPENSION OR DEFERRAL OF PAYMENT PROVISIONS OWNER, ANNUITANT AND BENEFICIARY THE ACCUMULATION PHASE PAYMENTS VALUES TRANSFER XXXXXXXXXX AND SURRENDER DEATH BENEFIT THE PAYOUT PHASE ANNUITY BENEFIT TRANSFER WITHDRAWAL PRESENT VALUE OF ANNUITY BENEFIT PAYMENTS DEATH OF THE ANNUITANT ANNUITY BENEFIT PAYMENT OPTIONS ANNUITY BENEFIT PAYMENT GUARANTEE OPTIONS ANNUITY OPTION TABLES GENERAL ANNUITANT, OWNERSHIP, ASSIGNMENT PROVISIONS Form A3031-99Owner Annuitant Assignment Of The Contract

RIGHT TO EXAMINE CONTRACT. The Owner This contract may cancel this contract be returned for cancellation within 10 days after the date it is received by returning it you. It may be delivered or mailed to the Company or one to any agent of its authorized representatives within ten days after receiptthe Company. If returned, This contract will then be cancelled as of the Date of Issue and the Company will refund to you an amount equal to: (a) all contributions allocated to the Accumulated ValueInterest Accumulation Account, after application with no deductions; plus (b) the value on the date of surrender of all contributions allocated to any Market Value Adjustment, plus any fees or other charges imposedInvestment Account associated with an Investment Fund of the Separate Account. If, howeverFor the purpose of this provision, the date of surrender will be the date this contract is issued as an Individual Retirement Annuity (IRA), delivered or mailed to the Company will refund the greater of the above or the gross paymentsfor cancellation. ALLMERICA FINANCIAL LIFE INSURANCE AND ANNUITY COMPANY Home Office: Dover, Delaware Principal Office: 000 Xxxxxxx Xxxxxx, Xxxxxxxxx, Xxxxxxxxxxxxx 00000 This is a legal The contract between Allmerica Financial Life Insurance and Annuity Company (the Company) and the Owner and is issued in consideration of the Initial Payment shown application for this contract and payment of the first required contribution. The contract will take effect on the Specifications pageEffective Date shown below. Additional Payments This page and the following pages are permitteda part of this contract. Payments may be allocated All benefits payable are subject to Variable Sub-Accounts, the Fixed Account or Guarantee Period Accountsprovisions of this contract. While this This contract is in effect, executed by the Company agrees to pay annuity benefit payments beginning at its Home Office in New York, New York on the Annuity Date or to pay a Death Benefit to the Beneficiary if an Owner dies prior to the Annuity Dateof Issue of this contract. /s/ Xxxxx Xxxxx /s/ Xxxxxx X. Xxxxx Vice President Secretary Flexible Payment Deferred Variable and Fixed Annuity Annuity Benefit Payments Payable on the Annuity Date Death Benefit Payable to Beneficiary if Owner Dies prior to Annuity Date Non-Participating Form A3031-99 TABLE Chairman, President & Chief Executive Officer ASSETS HELD IN CONNECTION WITH THIS CONTRACT MAY BE HELD IN THE COMPANY’S GENERAL ACCOUNT AND/OR THE COMPANY’S SEPARATE ACCOUNT THAT THE COMPANY MAINTAINS IN CONNECTION WITH THIS CONTRACT AND CERTAIN OTHER CONTRACTS. THE ASSETS OF CONTENTS SPECIFICATONS DEFINITIONS OWNER, THE SEPARATE ACCOUNT ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNTS AND WILL INCREASE OR DECREASE IN VALUE BASED UPON THE INVESTMENT RESULTS OF THE SEPARATE ACCOUNT. A DESCRIPTION OF THE SEPARATE ACCOUNT IS DESCRIBED IN THE PROVISION OF THIS CONTRACT ENTITLED “DESCRIPTION OF ACCOUNTS”. DEATH BENEFIT PAYABLE UPON YOUR DEATH BEFORE THE ANNUITY COMMENCEMENT DATE. THIS IS A PARTICIPATING CONTRACT. ANNUITANT AND BENEFICIARY THE ACCUMULATION PHASE PAYMENTS VALUES TRANSFER XXXXXXXXXX AND SURRENDER DEATH OWNER: (Herein called “you” and “your”) CONTRACT SPECIFICATIONS 5 BENEFIT THE PAYOUT PHASE PROVISIONS 5 MONTHLY ANNUITY BENEFIT TRANSFER WITHDRAWAL PRESENT VALUE BENEFITS 5 AMOUNT OF ANNUITY BENEFIT 5 ANNUITY COMMENCEMENT DATE 5 REQUIRED BEGINNING DATE 5 VALID TRANSACTION DATE 6 DISTRIBUTIONS 6 TERMINATION OF THIS CONTRACT 7 CONTRIBUTIONS 7 CONTRIBUTIONS 7 ALLOCATION OF CONTRIBUTIONS 8 ALLOCATIONS 8 CHANGE OF ALLOCATIONS 8 ACCUMULATION VALUE 8 ACCUMULATION VALUE 8 DESCRIPTION OF ACCOUNTS 9 TYPES OF ACCOUNTS 9 GENERAL ACCOUNT 10 SEPARATE ACCOUNT 10 ACCUMULATION UNITS 12 ACCUMULATION UNIT VALUE 12 ACCUMULATION UNIT VALUE CHANGE FACTOR 12 VALUATION DAY AND VALUATION PERIOD 12 CHANGES TO SEPARATE ACCOUNT 12 VALUATION OF ASSETS 12 STATEMENT OF ACCOUNTS 13 CHARGES 13 TYPES AND AMOUNTS OF CHARGES 13 CHANGE IN THE AMOUNT OF CHARGES 13 SPECIFIED PAYMENTS DEATH OPTIONS 14 ELECTION OF THE ANNUITANT SPECIFIED PAYMENTS OPTION 14 PAYMENT OF SPECIFIED AMOUNT 14 WITHDRAWALS AND TRANSFERS 14 WITHDRAWALS AND TRANSFERS 14 WITHDRAWALS 14 TRANSFERS 15 AMOUNT OF WITHDRAWAL OR TRANSFER 15 REQUESTS 15 POSTPONEMENT OF PAYMENTS, WITHDRAWALS OR TRANSFERS 15 ANNUITY BENEFIT PAYMENT OPTIONS 15 ELECTION OF FORM OF ANNUITY BENEFIT PAYMENT GUARANTEE OPTIONS ANNUITY 15 BENEFICIARY 16 CHANGE OF BENEFICIARY 17 FIXED AMOUNT OPTION TABLES 17 FIXED AMOUNT OPTION 17 GENERAL PROVISIONS Form A303117 THE CONTRACT 17 INCONTESTABILITY 17 MISSTATEMENTS OF AGE 18 ASSIGNMENT 18 CHANGES TO THIS CONTRACT 18 SURVIVAL OF PAYEE 18 CLAIMS OF CREDITORS 18 CORRESPONDENCE 18 PARTICIPATING CONTRACT 18 DIVIDENDS 18 REQUIRED INFORMATION 18 NON-99WAIVER 19 TABLE OF RATES 20

RIGHT TO EXAMINE CONTRACT. The Owner may cancel this contract by returning it to the Company or one of its authorized representatives within ten days after receipt. If returned, the Company will refund an amount equal to the Accumulated Value, after application of any Market Value Adjustment, plus any fees or other charges imposed. If, however, the contract is issued as an Individual Retirement Annuity (IRA), the Company will refund the greater of the above or the gross payments. ALLMERICA FINANCIAL LIFE INSURANCE AND ANNUITY COMPANY Home Office: Dover, Delaware Principal Office: 000 Xxxxxxx Xxxxxx, Xxxxxxxxx, Xxxxxxxxxxxxx 00000 This is a legal contract between Allmerica Financial Life Insurance and Annuity Company (the Company) and the Owner and is issued in consideration of the Initial Payment shown on the Specifications page. Additional Payments are permitted. Payments may be allocated to Variable Sub-Accounts, the Fixed Account or Guarantee Period Accounts. While this contract is in effect, the Company agrees to pay annuity benefit payments beginning on the Annuity Date or to pay a Death Benefit to the Beneficiary if an Owner dies prior to the Annuity Date. President Secretary Flexible Payment Deferred Variable and Fixed Annuity Annuity Benefit Payments Payable on the Annuity Date Death Benefit Payable to Beneficiary if Owner Dies prior to Annuity Date Non-Participating Form A3031A3030-99 1 TABLE OF CONTENTS SPECIFICATONS DEFINITIONS OWNER, ANNUITANT AND BENEFICIARY THE ACCUMULATION PHASE PAYMENTS VALUES TRANSFER XXXXXXXXXX AND SURRENDER DEATH BENEFIT THE PAYOUT PHASE ANNUITY BENEFIT TRANSFER WITHDRAWAL PRESENT VALUE OF ANNUITY BENEFIT PAYMENTS DEATH OF THE ANNUITANT ANNUITY BENEFIT PAYMENT OPTIONS ANNUITY BENEFIT PAYMENT GUARANTEE OPTIONS ANNUITY OPTION TABLES GENERAL PROVISIONS Form A3031A3030-9999 2 DEFINITIONS Accumulated Value The aggregate value of all accounts in this contract before the Annuity Date. As long as the Accumulated Value is greater than zero, the contract will stay in effect.