ALLMERICA FINANCIAL
LIFE INSURANCE AND 000 XXXXXXX XXXXXX, VARIABLE ANNUITY APPLICATION
ANNUITY COMPANY WORCESTER, MA 01653
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1. ANNUITANT
Please Print Clearly
First MI Last
___________________________________________________________________________
Street Address Apt.
___________________________________________________________________________
City State ZIP
___________________________________________________________________________
Daytime Telephone / / Male Date of Birth
( ) / / Female / /
___________________________________________________________________________
S.S.#
___________________________________________________________________________
_______________________________________________________________________________
2. OWNER COMPLETE THIS SECTION ONLY IF (CHECK ONE AND FILL IN BELOW):
Please Print Clearly
/ / THE OWNER IS OTHER THAN THE ANNUITANT, OR
/ / THIS IS A JOINT OWNER WITH THE ANNUITANT.
First MI Last
_______________________________________________________________________________
Street Address Apt.
_______________________________________________________________________________
City State Zip
_______________________________________________________________________________
S.S.#/Tax I.D. # Date of Birth Date of Trust
/ / / /
_______________________________________________________________________________
_______________________________________________________________________________
3. BENEFICIARY
/ /______ Day Common Disaster Clause
_______________________________________________________________________________
Primary Relationship to Annuitant
_______________________________________________________________________________
Contingent Relationship to Annuitant
_______________________________________________________________________________
4. TYPE OF PLAN
/ / 401(a) Pension/Profit Sharing* / / 408(k) SEP-IRA*
/ / 401(k) Profit Sharing* / / 457 Deferred Comp.
/ / 403(b) TSA* / / Non-Qual. Def. Comp.
/ / 408(b) IRA / / Non-Qualified
*Attach required additional forms.
_______________________________________________________________________________
5. INITIAL PAYMENT
Initial Payment $ _________________________________________
If IRA or SEP-IRA application, the applicant has received a
Disclosure Buyer's Guide and this payment is a (check one):
/ / Rollover / /Trustee to Trustee Transfer
/ / Regular or SEP-IRA Payment for Tax Year ___________
_______________________________________________________________________________
6. REPLACEMENT
Will the proposed contract replace or change any existing
annuity or insurance policy? / / NO / / YES
(If yes, list company name and policy number)
_________________________________________________________
_______________________________________________________________________________
7. ALLOCATION OF PAYMENTS
___________% Allmerica Select International Equity
___________% Delaware International Equity Series
___________% Fidelity VIP Overseas Portfolio
___________% X. Xxxx Price International Stock
___________% Allmerica Select Aggressive Growth
___________% Allmerica Select Capital Appreciation
___________% Allmerica Small Cap Value
___________% Allmerica Select Growth
___________% Allmerica Growth
___________% Fidelity VIP Growth Portfolio
___________% Allmerica Equity Index
___________% Allmerica Select Growth and Income
___________% Fidelity VIP Equity-Income Portfolio
___________% Fidelity VIP II Asset Manager Portfolio
___________% Fidelity VIP High Income Portfolio
___________% Allmerica Investment Grade Income
___________% Allmerica Government Bond
___________% Allmerica Money Market
___________% Fixed Account (Not available in OR)
Guarantee Period Accounts
($1,000 minimum per Account)
___________% 3 Year
___________% 5 Year
___________% 6 Year
___________% 7 Year
___________% 8 Year
___________% 9 Year
___________% 10 Year
1 0 0 % (All allocations above must total 100%)
___________
________________________________________________________________________
/ / I elect Automatic Account Rebalancing among the above accounts
(excluding the Fixed and Guarantee Period Accounts) starting on the
16th day after the issue date and continuing every:
/ / 1 / / 2 / / 3 / / 6 / / 12 Months
NOTE: If the contract applied for provides for a full refund of the
initial payment under its "Right to Examine" provision, that portion
of each payment not allocated to the Fixed Account will be allocated
solely to the Money Market account during its first 15 days.
Reallocation will then be made as specified.
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8. TELEPHONE TRANSFER
I/We authorize and direct Allmerica Financial Life Insurance and Annuity
Company to accept telephone instructions from any person who can furnish
proper identification to effect transfers and future payment allocation
changes. I agree to hold harmless and indemnify Allmerica Financial
Life Insurance and Annuity Company and its affiliates and their collective
directors, officers, employees and agents against any claim arising from
such action.
/ / I DO NOT accept this telephone transfer privilege.
_______________________________________________________________________________
SML-1443 (7/96)
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9. DOLLAR COST AVERAGING
Please transfer $_________________ from (check ONE source account)
($100 minimum)
/ / Fixed Account / / Government Bond / / Money Market
EVERY: / / 1 / / 2 / / 3 / / 6 / / 12 months
TO: ___________ % Allmerica Select International Equity
___________ % Delaware International Equity Series
___________ % Fidelity VIP Overseas Portfolio
___________ % X. Xxxx Price International Stock
___________ % Allmerica Select Aggressive Growth
___________ % Allmerica Select Capital Appreciation
___________ % Allmerica Small Cap Value
___________ % Allmerica Select Growth
___________ % Allmerica Growth
___________ % Fidelity VIP Growth Portfolio
___________ % Allmerica Equity Index
___________ % Allmerica Select Growth and Income
___________ % Fidelity VIP Equity-Income Portfolio
___________ % Fidelity VIP II Asset Manager Portfolio
___________ % Fidelity VIP High Income Portfolio
___________ % Allmerica Investment Grade Income
___________ % Allmerica Government Bond
___________ % Allmerica Money Market
Dollar Cost Averaging begins on the 16th day after the issue date and
ends when the source account value is exhausted.
DOLLAR COST AVERAGING INTO THE FIXED OR GUARANTEE PERIOD ACCOUNTS IS
NOT AVAILABLE.
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10. SYSTEMATIC WITHDRAWALS
Please withdraw $_________________
($100 minimum)
EVERY: / / 1 / / 2 / / 3 / / 6 / / 12 months
(Systematic withdrawls from the Guarantee Period Accounts are not available.)
___________ % From _______________________________
___________ % From _______________________________
___________ % From _______________________________
___________ % From _______________________________
___________ % From _______________________________
___________ % From _______________________________
___________ % From _______________________________
___________ % From _______________________________
___________ % From _______________________________
___________ % From _______________________________
1 0 0 % TOTAL
___________
/ / Do NOT Withhold Federal Income Taxes
/ / Do Withhold at 10% or _________ (% or $)
Systematic withdraws begin on the 16th day after the issue date.
/ / I wish to use Electronic Funds Transfer. I authorize the Company to
electronically correct any overpayments or erroneous credits made to
my account.
A VOIDED CHECK MUST BE ATTACHED.
_______________________________________________________________________________
11. OPTIONAL BILLING REMINDERS
/ / I wish to receive periodic reminders that I can include with future
remittances.
PAYMENT REMINDER REQUEST (FORM SML-1203) MUST BE ATTACHED.
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12. REMARKS
_______________________________________________________________________________
_______________________________________________________________________________
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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. 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, THE OPERATION OF WHICH MAY RESULT IN EITHER AN
UPWARD OR DOWNWARD ADJUSTMENT. I/We understand that unless I/we elect
otherwise, the Annuity Date will be the earlier of the date, if any,
selected by the Owner, or the later of the Annuitant's 85th birthday or
the birthday following the tenth contract anniversary, not to exceed
age 90.
____________________________________ ___________________________________
Signature of Owner Signed at (City and State) Date
____________________________________
Signature of Joint Owner
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14. REGISTERED REPRESENTATIVE/DEALER INFORMATION
Does the contract applied for replace an existing annuity or life
insurance policy?
/ / Yes / / No If yes, attach replacement form as required.
I CERTIFY THAT (1) THE INFORMATION PROVIDED BY THE OWNER HAS BEEN ACCURATELY
RECORDED; (2) A CURRENT PROSPECTUS WAS DELIVERED; (3) NO WRITTEN SALES
MATERIALS OTHER THAN THOSE APPROVED BY THE PRINCIPAL OFFICE WERE USED;
AND (4) I HAVE REASONABLE GROUNDS TO BELIEVE THE PURCHASE OF THE CONTRACT
APPLIED FOR IS SUITABLE FOR THE OWNER.
Date Signature of Registered Representative % TR Print Full Name Code Agency
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Date Signature of Registered Representative % TR Print Full Name Code Agency
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Date Signature of Registered Representative % TR Print Full Name Code Agency
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