PLEASE READ THIS CONTRACT CAREFULLY
Annuity payments and other values provided by this contract under the
Variable Income Options may increase or decrease and are not guaranteed as to
fixed dollar amount.
RIGHT TO EXAMINE CONTRACT
You may return this contract within 90 days after you have received it (the
"Free Look Period"). It can be mailed or delivered either to us or the
representative who sold it. If you return the contract, we will pay to you
the Contract Value on the date the contract is returned to us plus any
premium tax deducted on the Issue Date. This amount may be more or less than
the Single Purchase Payment.
ALLMERICA FINANCIAL LIFE INSURANCE AND ANNUITY COMPANY
Home Office: Dover, Delaware
Principal Office: 000 Xxxxxxx Xxxxxx, Xxxxxxxxx, Xxxxxxxxxxxxx 00000
Phone Number: 0-000-000-0000
This is a legal contract between you and the Company and is issued in
consideration of the Single Purchase Payment shown on the Specifications
page. The Net Payment may be allocated to the Fixed Income Option or the
Variable Income Option or a combination of both. If you select the Variable
Income Option, you can allocate the Net Payment among the Variable
Sub-Accounts.
Single Payment Immediate Variable and Fixed Annuity
Annuity Payments Payable on the Annuity Income Date
Death Benefit Payable if an Owner or an Annuitant Dies prior to
Annuity Income Date
This contract does not participate in the profits or surplus of the Company
FORM A3029-99
TABLE OF CONTENTS
SPECIFICATIONS ........................................................... 3
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION ................................ 5
DEFINITIONS .............................................................. 6
OWNER, ANNUITANT AND BENEFICIARY ......................................... 8
ANNUITY BENEFIT .......................................................... 10
OVERVIEW ..................................................... 10
VARIABLE INCOME OPTIONS ...................................... 11
WITHDRAWALS ................................................. 14
DEATH OF OWNER OR ANNUITANT ............................................... 17
BEFORE THE ANNUITY INCOME DATE .............................. 17
AFTER THE ANNUITY INCOME DATE ................................ 17
GENERAL PROVISIONS ....................................................... 18
FORM A3029-99 2
PLEASE READ THIS CONTRACT CAREFULLY
Annuity payments and other values provided by this contract under the
Variable Income Options may increase or decrease and are not guaranteed as to
fixed dollar amount.
RIGHT TO EXAMINE CONTRACT
You may return this contract within 90 days after you have received it. It
can be mailed or delivered either to us or the representative who sold it. If
you return the contract within 10 days after you have received it ("the Free
Look Period"), we will refund the Single Purchase Payment less the total
amount of all annuity payments made or withdrawals taken. If you return the
contract after the expiration of the "Free Look Period" but within 90 days
after the Issue Date, we will pay to you the Contract Value on the date the
contract is returned to us plus any premium tax deducted on the Issue Date.
ALLMERICA FINANCIAL LIFE INSURANCE AND ANNUITY COMPANY
Home Office: Dover, Delaware
Principal Office: 000 Xxxxxxx Xxxxxx, Xxxxxxxxx, Xxxxxxxxxxxxx 00000
Phone Number: 0-000-000-0000
This is a legal contract between you and the Company and is issued in
consideration of the Single Purchase Payment shown on the Specifications
page. The Net Payment may be allocated to the Fixed Income Option or the
Variable Income Option or a combination of both. If you select the Variable
Income Option, you can allocate the Net Payment among the Variable
Sub-Accounts.
Single Payment Immediate Variable and Fixed Annuity
Annuity Payments Payable on the Annuity Income Date
Death Benefit Payable if an Owner or an Annuitant Dies prior to
Annuity Income Date
This contract does not participate in the profits or surplus of the Company
FORM A3029.4-99
TABLE OF CONTENTS
SPECIFICATIONS .................................................... 3
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION ......................... 5
DEFINITIONS ........................................................ 6
OWNER, ANNUITANT AND BENEFICIARY ................................... 8
ANNUITY BENEFIT .................................................... 10
OVERVIEW .............................................. 10
VARIABLE INCOME OPTIONS ................................ 11
WITHDRAWALS ............................................ 14
DEATH OF OWNER OR ANNUITANT ......................................... 17
BEFORE THE ANNUITY INCOME DATE ......................... 17
AFTER THE ANNUITY INCOME DATE .......................... 17
GENERAL PROVISIONS .................................................. 18
FORM A3029-99 2
SPECIFICATIONS
ContractType:Non-qualified Single Purchase Payment Amount:
Contract Number:zz00600000 Net Payment:
Owner:Xxxx Xxx Owner's Date of Birth: 10/25/1960
Joint Owner:Xxxx Xxx Joint Owner's Date of Birth: 07/12/1960
Annuitant:Xxxx Xxx Xxxxxxxxx's Date of Birth: 03/19/1945
Joint Annuitant:Xxxxxxx Xxx Joint Annuitant's Date of Birth: 08/20/1954
Annuitant's Sex:Female Payee:Xxxx Xxx
Joint Annuitant's Sex:Male Payee's Address :0 Xxxx Xx, Xxxxxxxx, XXX
Primary Beneficiary:Surviving Joint Owner, if any
1st Contingent Beneficiary(ies):Xxxxxxx Xxx
2nd Contingent Beneficiary(ies):Xxxx Xxx
Issue Date:04/01/1999
Annuity Income Date:10/01/1999
Annuity Benefit Option: Joint Life Annuity with a Survivor Benefit Option (See page 5)
Survivor Benefit Percentage: 50%
Frequency of Annuity Payments: Monthly
Mortality Table: Annuity 2000
Percentage under a Fixed Income Option: 30%
Dollar Amount of Fixed Income: $
Percentage under a Variable Income Option: 70%
Assumed Investment Return: 5%
Change Frequency: Monthly
Date of First Change: xx/xx/xxxx
Income Option Rate: 4.5
Optional Feature:
The Ratchet:
Initial Ratchet Amount: $100
Ratchet Maximum Benefit Increase Percentage: 10%
If you had not selected this feature, the Income Option Rate above would have been 5.0.
The Floor:
Floor Amount: $100
If you had not selected this feature, the Income Option Rate above would have been 5.0.
FORM A8029-99 3
SPECIFICATIONS (CONTINUED)
Owner:Xxxx Xxx Contract Number:zz00600000
Joint Owner:Xxxx Xxx
Single Purchase Amount:$25,000.00
Payment Withdrawal Amount: 10 times the previous annuity payment.
But not more than the remaining guaranteed payments.
Present Value Withdrawal Amount: 75% of Present Value of remaining guaranteed annuity
payments.
Mortality and Expense Risk Charge: 1.25% on an annual basis of the daily value of the
Sub-Account assets.
Administrative Charge: .20% on an annual basis of the daily value of the
Sub-Account assets.
Variable Allocation of Net Payment on Issue Date:
Sub-Account Name Percentage of Net Payment Number of Units
----------------------------------------- --------------------------- ----------------
Select Aggr. Growth
Select Capital Appr.
Select Value Opp.
Select Emerging Markets
Select Int'l Equity
DGPF Int'l Equity Series
Fidelity VIP Overseas
X. Xxxx Price Int'l
Select Growth
Select Strategic Growth
Growth Fund
Fidelity VIP Growth
Equity Index Fund
Select Gr. & Inc.
Fidelity VIP Eq. Inc.
Fidelity VIP Asset Mgr
Fidelity VIP High Inc
Investment Grade Income Fund
Government Bond Fund
Allmerica Money Market
FORM A8029-99 4
SPECIFICATIONS
ContractType:Non-qualified Joint Annuitant:Xxxxxxx Xxx
Contract Number:zz00600000
Owner:Xxxx Xxx Xxxxxxxxx's Sex:Female
Joint Owner:Xxxx Xxx Joint Annuitant's Sex:Male
Annuitant:Xxxx Xxx Primary Beneficiary:Surviving Joint Owner, if any
1st Contingent Beneficiary(ies):Xxxxxxx Xxx
2nd Contingent Beneficiary(ies):Xxxx Xxx Single Purchase Payment Amount:
Net Payment:
Issue Date:04/01/1999
Annuity Income Date:10/01/1999 Owner's Date of Birth:10/25/1960
Joint Owner's Date of Birth:07/12/1960
Annuitant's Date of Birth:03/19/1945
Joint Annuitant's Date of Birth:08/20/1954
Payee:Xxxx Xxx
Xxxxx's Address :0 Xxxx Xx, Xxxxxxxx, XXX
Annuity Benefit Option: Joint Life Annuity with a Survivor Benefit Option (See page
5)
Survivor Benefit Percentage: 50%
Frequency of Annuity Payments: Monthly
Mortality Table: Annuity 2000
Percentage under a Fixed Income Option: 30%
Dollar Amount of Fixed Income: $
Percentage under a Variable Income Option: 70%
Assumed Investment Return: 5%
Change Frequency: Monthly
Date of First Change: xx/xx/xxxx
Income Option Rate: 4.5
Optional Feature:
The Ratchet:
Initial Ratchet Amount: $100
Ratchet Maximum Benefit Increase Percentage: 10%
If you had not selected this feature, the Income Option Rate above would have been 5.0.
The Floor:
Floor Amount: $100
If you had not selected this feature, the Income Option Rate above would have been 5.0.
FORM A8029-99 3
SPECIFICATIONS (CONTINUED)
Owner:Xxxx Xxx Contract Number:zz00600000
Joint Owner:Xxxx Xxx
Single Purchase Amount:$25,000.00
Payment Withdrawal Amount: 10 times the previous annuity payment.
But not more than the remaining guaranteed payments.
Present Value Withdrawal Amount: 75% of Present Value of remaining guaranteed annuity
payments.
Mortality and Expense Risk Charge: 1.25% on an annual basis of the daily value of the
Sub-Account assets.
Administrative Charge: .20% on an annual basis of the daily value of the
Sub-Account assets.
Variable Allocation of Net Payment on Issue Date:
Sub-Account Name Percentage of Net Payment Number of Units
-------------------------------------- ------------------------- -----------------
Select Aggr. Growth
Select Capital Appr.
Select Value Opp.
Select Emerging Markets
Select Int'l Equity
DGPF Int'l Equity Series
Fidelity VIP Overseas
X. Xxxx Price Int'l
Select Growth
Select Strategic Growth
Growth Fund
Fidelity VIP Growth
Equity Index Fund
Select Gr. & Inc.
Fidelity VIP Eq. Inc.
Fidelity VIP Asset Mgr
Fidelity VIP High Inc
Investment Grade Income Fund
Government Bond Fund
Allmerica Money Market
FORM A8029-99 4
SPECIFICATIONS
ContractType:Non-qualified Issue Date:04/01/1999
Contract Number:zz00600000 Annuity Income Date:10/01/1999
Owner:Xxxx Xxx
Joint Owner:Xxxx Xxx
Annuitant:Xxxx Xxx
Joint Annuitant:Xxxxxxx Xxx
Annuitant's Sex:Female
Joint Annuitant's Sex:Male
Primary Beneficiary:Surviving Joint Owner, if any
1st Contingent Beneficiary(ies):Xxxxxxx Xxx
2nd Contingent Beneficiary(ies):Xxxx Xxx
Single Purchase Payment Amount:
Net Payment:
Owner's Date of Birth:10/25/1960
Joint Owner's Date of Birth:07/12/1960
Annuitant's Date of Birth:03/19/1945
Joint Annuitant's Date of Birth:08/20/1954
Payee:Xxxx Xxx
Xxxxx's Address :0 Xxxx Xx, Xxxxxxxx, XXX
Annuity Benefit Option: Joint Life Annuity with a Survivor Benefit Option (See page 5)
Survivor Benefit Percentage: 50%
Frequency of Annuity Payments: Monthly
Mortality Table: Annuity 2000
Percentage under a Fixed Income Option: 30%
Dollar Amount of Fixed Income: $
Percentage under a Variable Income Option: 70%
Assumed Investment Return: 5%
Change Frequency: Monthly
Date of First Change: xx/xx/xxxx
Income Option Rate: 4.5
Optional Feature:
The Ratchet:
Initial Ratchet Amount: $100
Ratchet Maximum Benefit Increase Percentage: 10%
If you had not selected this feature, the Income Option Rate above would have been 5.0.
The Floor:
Floor Amount: $100
If you had not selected this feature, the Income Option Rate above would have been 5.0.
FORM A8029-99 3
SPECIFICATIONS (CONTINUED)
Owner:Xxxx Xxx Contract Number:zz00600000
Joint Owner:Xxxx Xxx
Single Purchase Amount:$25,000.00
Payment Withdrawal Amount: 10 times the previous annuity payment.
But not more than the remaining guaranteed payments.
Present Value Withdrawal Amount: 75% of Present Value of remaining guaranteed annuity
payments.
Mortality and Expense Risk Charge: 1.25% on an annual basis of the daily value of the
Sub-Account assets.
Administrative Charge: .20% on an annual basis of the daily value of the
Sub-Account assets.
Variable Allocation of Net Payment on Issue Date:
Sub-Account Name Percentage of Net Payment Number of Units
--------------------------------- ------------------------- ----------------
Select Aggr. Growth
Select Capital Appr.
Select Value Opp.
Select Emerging Markets
Select Int'l Equity
DGPF Int'l Equity Series
Fidelity VIP Overseas
X. Xxxx Price Int'l
Select Growth
Select Strategic Growth
Growth Fund
Fidelity VIP Growth
Equity Index Fund
Select Gr. & Inc.
Fidelity VIP Eq. Inc.
Fidelity VIP Asset Mgr
Fidelity VIP High Inc
Investment Grade Income Fund
Government Bond Fund
Allmerica Money Market
FORM A8029-99 4
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Payment for a Certain Number of Years:
We will provide annuity payments, beginning on the Annuity
Income Date, for the period of time shown on the
Specifications Page.
FORM A3029-99 5
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Payment for a Certain Number of Years, with a Ratchet:
We will provide annuity payments, beginning on the Annuity
Income Date, for the period of time shown on the
Specifications Page.
The Ratchet is an optional feature you have selected that is applicable only
to the Variable Income Option. It guarantees that annuity payments will never
decrease as a result of investment performance.
Annuity payments made prior to the Date of First Change are guaranteed to
equal or exceed the Initial Ratchet Amount shown on the Specifications Page.
All other annuity payments are guaranteed to equal or exceed the Current
Ratchet Amount. The Current Ratchet Amount equals the amount of the last
annuity payment in the previous Change Frequency Cycle.
From one Change Frequency Cycle to the next, annuity payments are limited so
that they will not exceed the applicable ratchet amount by more than the
Ratchet Maximum Benefit Increase Percentage (see Specifications Page).
If you take a withdrawal from the contract, the Initial Ratchet Amount (if
the withdrawal is taken prior to the Date of First Change) or the Current
Ratchet Amount (if the withdrawal is taken at any other time) will be reduced
in the same manner that the withdrawal reduces the Annuity Units.
There is no periodic charge for this feature. Instead, lower Income Option
Rates are used to determine your first variable annuity payment. As a result,
the first annuity payment is lower than it would have been had this feature
not been selected. Future annuity payments will also be lower except when the
protection provided by this feature results in a greater benefit.
FORM A3029-99 5
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Payment for a Certain Number of Years, with a Floor:
We will provide annuity payments, beginning on the Annuity
Income Date, for the period of time shown on the
Specifications Page.
The Floor is an optional feature you have selected that is applicable only to
the Variable Income Option. While variable annuity payments may increase or
decrease, this feature guarantees that they will never fall below the Floor
Amount.
The Floor Amount is shown on the Specifications Page. If you take a
withdrawal from the contract, the Floor Amount will be reduced in the same
manner that the withdrawal reduces the Annuity Units.
There is no periodic charge for this feature. Instead, lower Income Option
Rates are used to determine your first variable annuity payment. As a result,
the first annuity payment is lower than it would have been had this feature
not been selected. Future annuity payments will also be lower except when the
protection provided by this feature results in a greater benefit.
FORM A3029-99 5
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Single Life Annuity:
We will provide annuity payments, beginning on the Annuity
Income Date, during the life of the sole Annuitant. We may
require satisfactory proof that the Annuitant is alive
before any annuity payment is made.
FORM A3029-99 5
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Single Life Annuity, with a Ratchet:
We will provide annuity payments, beginning on the Annuity
Income Date, during the life of the sole Annuitant. We may
require satisfactory proof that the Annuitant is alive
before any annuity payment is made.
The Ratchet is an optional feature you have selected that is applicable only
to the Variable Income Option. It guarantees that annuity payments will never
decrease as a result of investment performance.
Annuity payments made prior to the Date of First Change are guaranteed to
equal or exceed the Initial Ratchet Amount shown on the Specifications Page.
All other annuity payments are guaranteed to equal or exceed the Current
Ratchet Amount. The Current Ratchet Amount equals the amount of the last
annuity payment in the previous Change Frequency Cycle.
From one Change Frequency Cycle to the next, annuity payments are limited so
that they will not exceed the applicable ratchet amount by more than the
Ratchet Maximum Benefit Increase Percentage (see Specifications Page).
If you take a withdrawal from the contract, the Initial Ratchet Amount (if
the withdrawal is taken prior to the Date of First Change) or the Current
Ratchet Amount (if the withdrawal is taken at any other time) will be reduced
in the same manner that the withdrawal reduces the Annuity Units.
There is no periodic charge for this feature. Instead, lower Income Option
Rates are used to determine your first variable annuity payment. As a result,
the first annuity payment is lower than it would have been had this feature
not been selected. Future annuity payments will also be lower except when the
protection provided by this feature results in a greater benefit.
FORM A3029-99 5
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Single Life Annuity, with a Floor:
We will provide annuity payments, beginning on the Annuity
Income Date, during the life of the sole Annuitant. We may
require satisfactory proof that the Annuitant is alive
before any annuity payment is made.
The Floor is an optional feature you have selected that is applicable only to
the Variable Income Option. While variable annuity payments may increase or
decrease, this feature guarantees that they will never fall below the Floor
Amount.
The Floor Amount is shown on the Specifications Page. If you take a
withdrawal from the contract, the Floor Amount will be reduced in the same
manner that the withdrawal reduces the Annuity Units.
There is no periodic charge for this feature. Instead, lower Income Option
Rates are used to determine your first variable annuity payment. As a result,
the first annuity payment is lower than it would have been had this feature
not been selected. Future annuity payments will also be lower except when the
protection provided by this feature results in a greater benefit.
FORM A3029-99 5
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Joint Life Annuity with a Survivor Benefit:
We will provide annuity payments, beginning on the Annuity
Income Date, during the joint lifetime of both Annuitants.
Upon the death of an Annuitant, the number of Annuity
Units (for Variable Income Options) and/or the dollar
amount (for Fixed Income Options) of each payment will be
adjusted by the Survivor Benefit Percentage.
The Survivor Benefit Percentage is the percentage of
Annuity Units or dollars of each payment paid during the
survivor's life, which may be less than or equal to that
paid when both individuals are living. This percentage is
only applicable after the death of the first Annuitant.
We may require satisfactory proof that the Annuitants are alive before any
annuity payment is made.
FORM A3029-99 5
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Joint Life Annuity with a Survivor Benefit, with a Ratchet:
We will provide annuity payments, beginning on the Annuity
Income Date, during the joint lifetime of both Annuitants.
Upon the death of an Annuitant, the number of Annuity
Units (for Variable Income Options) and/or the dollar
amount (for Fixed Income Options) of each payment will be
adjusted by the Survivor Benefit Percentage.
The Survivor Benefit Percentage is the percentage of
Annuity Units or dollars of each payment paid during the
survivor's life, which may be less than or equal to that
paid when both individuals are living. This percentage is
only applicable after the death of the first Annuitant.
We may require satisfactory proof that the Annuitants are
alive before any annuity payment is made.
The Ratchet is an optional feature you have selected that is applicable only
to the Variable Income Option. It guarantees that annuity payments will never
decrease as a result of investment performance.
Annuity payments made prior to the Date of First Change are guaranteed to
equal or exceed the Initial Ratchet Amount shown on the Specifications Page.
All other annuity payments are guaranteed to equal or exceed the Current
Ratchet Amount. The Current Ratchet Amount equals the amount of the last
annuity payment in the previous Change Frequency Cycle. Upon the death of the
first Annuitant, the Current Ratchet Amount is adjusted by multiplying it by
the Survivor Benefit Percentage.
From one Change Frequency Cycle to the next, annuity payments are limited so
that they will not exceed the applicable ratchet amount by more than the
Ratchet Maximum Benefit Increase Percentage (see Specifications Page).
If you take a withdrawal from the contract, the Initial Ratchet Amount (if
the withdrawal is taken prior to the Date of First Change) or the Current
Ratchet Amount (if the withdrawal is taken at any other time) will be reduced
in the same manner that the withdrawal reduces the Annuity Units.
There is no periodic charge for this feature. Instead, lower Income Option
Rates are used to determine your first variable annuity payment. As a result,
the first annuity payment is lower than it would have been had this feature
not been selected. Future annuity payments will also be lower except when the
protection provided by this feature results in a greater benefit.
FORM A3029-99 5
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Joint Life Annuity with a Survivor Benefit, with a Floor:
We will provide annuity payments, beginning on the Annuity
Income Date, during the joint lifetime of both Annuitants.
Upon the death of an Annuitant, the number of Annuity
Units (for Variable Income Options) and/or the dollar
amount (for Fixed Income Options) of each payment will be
adjusted by the Survivor Benefit Percentage.
The Survivor Benefit Percentage is the percentage of Annuity Units or dollars
of each payment paid during the survivor's life, which may be less than or
equal to that paid when both individuals are living. This percentage is only
applicable after the death of the first Annuitant.
We may require satisfactory proof that the Annuitants are alive before any
annuity payment is made.
The Floor is an optional feature you have selected that is applicable only to
the Variable Income Option. While variable annuity payments may increase or
decrease, this feature guarantees that they will never fall below the Floor
Amount.
The Floor Amount is shown on the Specifications Page. Upon the death of the
first Annuitant, the Floor Amount is adjusted by multiplying it by the
Survivor Benefit Percentage. If you take a withdrawal from the contract, the
Floor Amount will be reduced in the same manner that the withdrawal reduces
the Annuity Units.
There is no periodic charge for this feature. Instead, lower Income Option
Rates are used to determine your first variable annuity payment. As a result,
the first annuity payment is lower than it would have been had this feature
not been selected. Future annuity payments will also be lower except when the
protection provided by this feature results in a greater benefit.
FORM A3029-99 5
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Single Life Annuity with Payment for a Certain Number of Years:
We will provide annuity payments, beginning on the Annuity
Income Date, during the life of the sole Annuitant with a
guarantee that if, at the Annuitant's death, annuity
payments have been made for less than the number of years
elected, then annuity payments will continue thereafter to
you (or the payee you designate) for the remainder of the
period. We may require satisfactory proof that the
Annuitant is alive before any annuity payment is made.
FORM A3029-99 5
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Single Life Annuity with Payment for a Certain Number of Years, with a Ratchet:
We will provide annuity payments, beginning on the Annuity
Income Date, during the life of the sole Annuitant with a
guarantee that if, at the Annuitant's death, annuity
payments have been made for less than the number of years
elected, then annuity payments will continue thereafter to
you (or the payee you designate) for the remainder of the
period. We may require satisfactory proof that the
Annuitant is alive before any annuity payment is made.
The Ratchet is an optional feature you have selected that is applicable only
to the Variable Income Option. It guarantees that annuity payments will never
decrease as a result of investment performance.
Annuity payments made prior to the Date of First Change are guaranteed to
equal or exceed the Initial Ratchet Amount shown on the Specifications Page.
All other annuity payments are guaranteed to equal or exceed the Current
Ratchet Amount. The Current Ratchet Amount equals the amount of the last
annuity payment in the previous Change Frequency Cycle.
From one Change Frequency Cycle to the next, annuity payments are limited so
that they will not exceed the applicable ratchet amount by more than the
Ratchet Maximum Benefit Increase Percentage (see Specifications Page).
If you take a withdrawal from the contract, the Initial Ratchet Amount (if
the withdrawal is taken prior to the Date of First Change) or the Current
Ratchet Amount (if the withdrawal is taken at any other time) will be reduced
in the same manner that the withdrawal reduces the Annuity Units.
There is no periodic charge for this feature. Instead, lower Income Option
Rates are used to determine your first variable annuity payment. As a result,
the first annuity payment is lower than it would have been had this feature
not been selected. Future annuity payments will also be lower except when the
protection provided by this feature results in a greater benefit.
FORM A3029-99 5
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Single Life Annuity with Payment for a Certain Number of Years, with a Floor:
We will provide annuity payments, beginning on the Annuity
Income Date, during the life of the sole Annuitant with a
guarantee that if, at the Annuitant's death, annuity
payments have been made for less than the number of years
elected, then annuity payments will continue thereafter to
you (or the payee you designate) for the remainder of the
period. We may require satisfactory proof that the
Annuitant is alive before any annuity payment is made.
The Floor is an optional feature you have selected that is applicable only to
the Variable Income Option. While variable annuity payments may increase or
decrease, this feature guarantees that they will never fall below the Floor
Amount.
The Floor Amount is shown on the Specifications Page. If you take a
withdrawal from the contract, the Floor Amount will be reduced in the same
manner that the withdrawal reduces the Annuity Units.
There is no periodic charge for this feature. Instead, lower Income Option
Rates are used to determine your first variable annuity payment. As a result,
the first annuity payment is lower than it would have been had this feature
not been selected. Future annuity payments will also be lower except when the
protection provided by this feature results in a greater benefit.
FORM A3029-99 5
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Joint Life Annuity with a Survivor Benefit, with Payment for a Certain Number of
Years:
We will provide annuity payments, beginning on the Annuity
Income Date, during the joint lifetime of both Annuitants
with a guarantee that if, upon the death of both
Annuitants, annuity payments have been made for less than
the number of years elected, then annuity payments will
continue thereafter to you (or the payee you designate)
for the remainder of the period. Upon the death of an
Annuitant, the number of Annuity Units (for Variable
Income Options) and/or the dollar amount (for Fixed Income
Options) of each payment will be adjusted by the Survivor
Benefit Percentage.
The Survivor Benefit Percentage is the percentage of Annuity Units or dollars
of each payment paid during the survivor's life, which may be less than or
equal to that paid when both individuals are living. This percentage is only
applicable after the death of the first Annuitant.
We may require satisfactory proof that the Annuitants are alive before any
annuity payment is made.
FORM A3029-99 5
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Joint Life Annuity with a Survivor Benefit, with Payment for a Certain Number of
Years, with a Ratchet:
We will provide annuity payments, beginning on the Annuity
Income Date, during the joint lifetime of both Annuitants
with a guarantee that if, upon the death of both
Annuitants, annuity payments have been made for less than
the number of years elected, then annuity payments will
continue thereafter to you (or the payee you designate)
for the remainder of the period. Upon the death of an
Annuitant, the number of Annuity Units (for Variable
Income Options) and/or the dollar amount (for Fixed Income
Options) of each payment will be adjusted by the Survivor
Benefit Percentage.
The Survivor Benefit Percentage is the percentage of Annuity Units or dollars
of each payment paid during the survivor's life, which may be less than or
equal to that paid when both individuals are living. This percentage is only
applicable after the death of the first Annuitant.
We may require satisfactory proof that the Annuitants are alive before any
annuity payment is made. The Ratchet is an optional feature you have selected
that is applicable only to the Variable Income Option. It guarantees that
annuity payments will never decrease as a result of investment performance.
Annuity payments made prior to the Date of First Change are guaranteed to
equal or exceed the Initial Ratchet Amount shown on the Specifications Page.
All other annuity payments are guaranteed to equal or exceed the Current
Ratchet Amount. The Current Ratchet Amount equals the amount of the last
annuity payment in the previous Change Frequency Cycle. Upon the death of the
first Annuitant, the Current Ratchet Amount is adjusted by multiplying it by
the Survivor Benefit Percentage.
From one Change Frequency Cycle to the next, annuity payments are limited so
that they will not exceed the applicable ratchet amount by more than the
Ratchet Maximum Benefit Increase Percentage (see Specifications Page).
If you take a withdrawal from the contract, the Initial Ratchet Amount (if
the withdrawal is taken prior to the Date of First Change) or the Current
Ratchet Amount (if the withdrawal is taken at any other time) will be reduced
in the same manner that the withdrawal reduces the Annuity Units.
There is no periodic charge for this feature. Instead, lower Income Option
Rates are used to determine your first variable annuity payment. As a result,
the first annuity payment is lower than it would have been had this feature
not been selected. Future annuity payments will also be lower except when the
protection provided by this feature results in a greater benefit.
FORM A3029-99 5
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Joint Life Annuity with a Survivor Benefit, with Payment for a Certain Number
of Years, with a Floor:
We will provide annuity payments, beginning on the Annuity
Income Date, during the joint lifetime of both Annuitants
with a guarantee that if, upon the death of both
Annuitants, annuity payments have been made for less than
the number of years elected, then annuity payments will
continue thereafter to you (or the payee you designate)
for the remainder of the period. Upon the death of an
Annuitant, the number of Annuity Units (for Variable
Income Options) and/or the dollar amount (for Fixed Income
Options) of each payment will be adjusted by the Survivor
Benefit Percentage.
The Survivor Benefit Percentage is the percentage of Annuity Units or dollars
of each payment paid during the survivor's life, which may be less than or
equal to that paid when both individuals are living. This percentage is only
applicable after the death of the first Annuitant.
We may require satisfactory proof that the Annuitants are alive before any
annuity payment is made.
The Floor is an optional feature you have selected that is applicable only to
the Variable Income Option. While variable annuity payments may increase or
decrease, this feature guarantees that they will never fall below the Floor
Amount.
The Floor Amount is shown on the Specifications Page. Upon the death of the
first Annuitant, the Floor Amount is adjusted by multiplying it by the
Survivor Benefit Percentage. If you take a withdrawal from the contract, the
Floor Amount will be reduced in the same manner that the withdrawal reduces
the Annuity Units.
There is no periodic charge for this feature. Instead, lower Income Option
Rates are used to determine your first variable annuity payment. As a result,
the first annuity payment is lower than it would have been had this feature
not been selected. Future annuity payments will also be lower except when the
protection provided by this feature results in a greater benefit.
FORM A3029-99 5
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Single Life Annuity with Cash Back:
We will provide annuity payments, beginning on the Annuity
Income Date, during the life of the sole Annuitant with a
guarantee that at the Annuitant's death, you (or the payee
you designate) will receive any excess of the Net Payment
applied over the total amount of annuity payments made and
withdrawals taken. We may require satisfactory proof that
the Annuitant is alive before any annuity payment is made.
FORM A3029-99 5
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Single Life Annuity with Cash Back, with a Ratchet:
We will provide annuity payments, beginning on the Annuity
Income Date, during the life of the sole Annuitant with a
guarantee that at the Annuitant's death, you (or the payee
you designate) will receive any excess of the Net Payment
applied over the total amount of annuity payments made and
withdrawals taken. We may require satisfactory proof that
the Annuitant is alive before any annuity payment is made.
The Ratchet is an optional feature you have selected that is applicable only
to the Variable Income Option. It guarantees that annuity payments will never
decrease as a result of investment performance.
Annuity payments made prior to the Date of First Change are guaranteed to
equal or exceed the Initial Ratchet Amount shown on the Specifications Page.
All other annuity payments are guaranteed to equal or exceed the Current
Ratchet Amount. The Current Ratchet Amount equals the amount of the last
annuity payment in the previous Change Frequency Cycle.
From one Change Frequency Cycle to the next, annuity payments are limited so
that they will not exceed the applicable ratchet amount by more than the
Ratchet Maximum Benefit Increase Percentage (see Specifications Page).
If you take a withdrawal from the contract, the Initial Ratchet Amount (if
the withdrawal is taken prior to the Date of First Change) or the Current
Ratchet Amount (if the withdrawal is taken at any other time) will be reduced
in the same manner that the withdrawal reduces the Annuity Units.
There is no periodic charge for this feature. Instead, lower Income Option
Rates are used to determine your first variable annuity payment. As a result,
the first annuity payment is lower than it would have been had this feature
not been selected. Future annuity payments will also be lower except when the
protection provided by this feature results in a greater benefit.
FORM A3029-99 5
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Single Life Annuity with Cash Back, with a Floor:
We will provide annuity payments, beginning on the Annuity
Income Date, during the life of the sole Annuitant with a
guarantee that at the Annuitant's death, you (or the payee
you designate) will receive any excess of the Net Payment
applied over the total amount of annuity payments made and
withdrawals taken. We may require satisfactory proof that
the Annuitant is alive before any annuity payment is made.
The Floor is an optional feature you have selected that is applicable only to
the Variable Income Option. While variable annuity payments may increase or
decrease, this feature guarantees that they will never fall below the Floor
Amount.
The Floor Amount is shown on the Specifications Page. If you take a
withdrawal from the contract, the Floor Amount will be reduced in the same
manner that the withdrawal reduces the Annuity Units.
There is no periodic charge for this feature. Instead, lower Income Option
Rates are used to determine your first variable annuity payment. As a result,
the first annuity payment is lower than it would have been had this feature
not been selected. Future annuity payments will also be lower except when the
protection provided by this feature results in a greater benefit.
FORM A3029-99 5
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Joint Life Annuity with a Survivor Benefit, with Cash Back:
We will provide annuity payments, beginning on the Annuity
Income Date, during the joint lifetime of both Annuitants
with a guarantee that, upon the death of both Annuitants,
you (or the payee you designate) will receive any excess
of the Net Payment applied over the total amount of
annuity payments made and withdrawals taken. Upon the
death of an Annuitant, the number of Annuity Units (for
Variable Income Options) and/or the dollar amount (for
Fixed Income Options) of each payment will be adjusted by
the Survivor Benefit Percentage.
The Survivor Benefit Percentage is the percentage of Annuity Units or dollars
of each payment paid during the survivor's life, which may be less than or
equal to that paid when both individuals are living. This percentage is only
applicable after the death of the first Annuitant.
We may require satisfactory proof that the Annuitants are alive before any
annuity payment is made.
FORM A3029-99 5
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Joint Life Annuity with a Survivor Benefit, with Cash Back, with a Ratchet:
We will provide annuity payments, beginning on the Annuity
Income Date, during the joint lifetime of both Annuitants
with a guarantee that, upon the death of both Annuitants,
you (or the payee you designate) will receive any excess
of the Net Payment applied over the total amount of
annuity payments made and withdrawals taken. Upon the
death of an Annuitant, the number of Annuity Units (for
Variable Income Options) and/or the dollar amount (for
Fixed Income Options) of each payment will be adjusted by
the Survivor Benefit Percentage.
The Survivor Benefit Percentage is the percentage of Annuity Units or dollars
of each payment paid during the survivor's life, which may be less than or
equal to that paid when both individuals are living. This percentage is only
applicable after the death of the first Annuitant.
We may require satisfactory proof that the Annuitants are alive before any
annuity payment is made.
The Ratchet is an optional feature you have selected that is applicable only
to the Variable Income Option. It guarantees that annuity payments will never
decrease as a result of investment performance.
Annuity payments made prior to the Date of First Change are guaranteed to
equal or exceed the Initial Ratchet Amount shown on the Specifications Page.
All other annuity payments are guaranteed to equal or exceed the Current
Ratchet Amount. The Current Ratchet Amount equals the amount of the last
annuity payment in the previous Change Frequency Cycle. Upon the death of the
first Annuitant, the Current Ratchet Amount is adjusted by multiplying it by
the Survivor Benefit Percentage.
From one Change Frequency Cycle to the next, annuity payments are limited so
that they will not exceed the applicable ratchet amount by more than the
Ratchet Maximum Benefit Increase Percentage (see Specifications Page).
If you take a withdrawal from the contract, the Initial Ratchet Amount (if
the withdrawal is taken prior to the Date of First Change) or the Current
Ratchet Amount (if the withdrawal is taken at any other time) will be reduced
in the same manner that the withdrawal reduces the Annuity Units.
There is no periodic charge for this feature. Instead, lower Income Option
Rates are used to determine your first variable annuity payment. As a result,
the first annuity payment is lower than it would have been had this feature
not been selected. Future annuity payments will also be lower except when the
protection provided by this feature results in a greater benefit.
FORM A3029-99 5
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Joint Life Annuity with a Survivor Benefit, with Cash Back, with a Floor:
We will provide annuity payments, beginning on the Annuity
Income Date, during the joint lifetime of both Annuitants
with a guarantee that, upon the death of both Annuitants,
you (or the payee you designate) will receive any excess
of the Net Payment applied over the total amount of
annuity payments made and withdrawals taken. Upon the
death of an Annuitant, the number of Annuity Units (for
Variable Income Options) and/or the dollar amount (for
Fixed Income Options) of each payment will be adjusted by
the Survivor Benefit Percentage.
The Survivor Benefit Percentage is the percentage of Annuity Units or dollars
of each payment paid during the survivor's life, which may be less than or
equal to that paid when both individuals are living. This percentage is only
applicable after the death of the first Annuitant.
We may require satisfactory proof that the Annuitants are alive before any
annuity payment is made.
The Floor is an optional feature you have selected that is applicable only to
the Variable Income Option. While variable annuity payments may increase or
decrease, this feature guarantees that they will never fall below the Floor
Amount.
The Floor Amount is shown on the Specifications Page. Upon the death of the
first Annuitant, the Floor Amount is adjusted by multiplying it by the
Survivor Benefit Percentage. If you take a withdrawal from the contract, the
Floor Amount will be reduced in the same manner that the withdrawal reduces
the Annuity Units.
There is no periodic charge for this feature. Instead, lower Income Option
Rates are used to determine your first variable annuity payment. As a result,
the first annuity payment is lower than it would have been had this feature
not been selected. Future annuity payments will also be lower except when the
protection provided by this feature results in a greater benefit.
FORM A3029-99 5
DEFINITIONS
Annuitant The person who must be alive for annuity
payments to be made (unless payments are
guaranteed). Joint Annuitants are permitted
and unless otherwise indicated, any reference
to Annuitant shall include joint Annuitants.
Annuity Income Date The date annuity payments begin. The Annuity
Income Date is shown on the Specifications Page.
Annuity Unit A measure used to calculate annuity payments under
a Variable Income Option.
Beneficiary The person, persons or entity entitled to the Death
Benefit upon the death of the Owner prior to the
Annuity Income Date or remaining annuity payments, if
any, upon the death of the Owner on or after the
Annuity Income Date.
Change Frequency How often changes (due to investment performance) will be
reflected in the dollar value of the variable annuity
payments. For example, if you choose an annual Change
Frequency, the dollar value of variable annuity payments
will remain constant within each one-year period.
Company, we, us or Allmerica Financial Life Insurance and Annuity Company.
our
Contract Value The Present Value of all remaining annuity payments.
Contract Year A one-year period based on the Issue Date or an anniversary
thereof.
Date of First Change The date on which your variable annuity payment will change
in value for the first time.
Effective Valuation Date The Valuation Date on or immediately following the day we
receive the Single Purchase Payment, request for
transfer, withdrawal, or proof of death.
Fund Each separate investment company, investment series or
portfolio eligible for investment by a Sub-Account of the
Variable Account.
General Account All assets of the Company that are not allocated to a
Separate Account.
Net Payment The Single Purchase Payment less any premium tax.
FORM A3029-99 6
Owner, you or your The person, persons or entity entitled to
exercise the rights and privileges under this contract.
Joint Owners are permitted and unless otherwise indicated,
any reference to you and your shall include joint Owners.
Premium Tax The amount of tax, if any, imposed by a State or other
governmental entity upon our receipt of the Single Purchase
Payment.
Pro Rata The way a withdrawal is deducted from the accounts.
To determine how the withdrawal is made, assume an annuity
payment is made on the date of the withdrawal. Compare the
value of the payment from each account to the total
annuity payment. The withdrawal from each account will be
made in the same proportion.
Request A request or notice made by you, in a manner consistent with
our current procedures, which is received by us.
Separate Account A segregated account established by us. The assets in
a Separate Account are not commingled with our general
assets and obligations and are not subject to claims arising
out of any other business we may conduct.
State The state or jurisdiction in which this contract is issued.
Sub-Account A Variable Account subdivision that corresponding Fund.
Valuation Date A day the values of all units are determined. Valuation
Dates occur on each day the New York Stock Exchange is
open for trading.
Valuation Period The period of time between two consecutive Valuation Dates.
Variable Account The Company's Separate Account, consisting of Sub-Accounts
that invest in the underlying Funds.
FORM A3029-99 7
OWNER, ANNUITANT AND BENEFICIARY
Owner The Owner is shown on the Specifications Page. Upon the death
of an Owner prior to the Annuity Income Date, a Death
Benefit is paid.
You may exercise all rights and options granted in this contract
or by us, subject to the consent of any irrevocable Beneficiary
(where applicable). Where there are joint Owners, the consent of
both is required in order to exercise any ownership rights.
Assignment You may not assign this contract.
Annuitant The Annuitant is as shown on the Specifications Page. Upon the death of
an Annuitant prior to the Annuity Income Date, a Death Benefit is paid.
Beneficiary The Beneficiary is as shown on the Specifications Page unless subsequently
changed. You may declare any Beneficiary to be revocable or
irrevocable. A revocable Beneficiary may be changed at any time (a)
before the Annuity Income Date and before the death of an Owner or
Annuitant; or (b) after the Annuity Income Date and before the death of
the Annuitant. An irrevocable Beneficiary must consent in writing to any
change of beneficiary. Unless otherwise indicated, the Beneficiary will
be revocable.
A Beneficiary change must be made by Request. When we receive the Request,
the change will take place as of the date it was signed, even if an Owner or
an Annuitant dies after the form is signed but prior to our receipt of the
Request. Any rights created by the change will be subject to payments we
made or actions taken before the change was recorded.
All benefits payable to the Beneficiary under this contract will be divided
equally among the surviving Beneficiaries of the same class (see
your Specifications Page), unless you direct otherwise. If there is no
surviving Beneficiary in a particular class, then the benefit is divided
equally among the surviving Beneficiaries of the next class. If
there is no surviving Beneficiary, the deceased Beneficiary's interest will
pass to you or your estate. If your contract has Joint Owners, and one Owner
dies, the surviving joint Owner is the primary Beneficiary. This is confirmed
on the Specifications page.
FORM A3029-99 8
Once entitled to benefits under this contract, the Beneficiary may transfer
or commute the annuity payments or any values provided as long as he or she has
been given that right by you.
Protection of Proceeds To the extent allowed by law, this contract and any payments made
under it will be exempt from the claims of creditors.
FORM A3029-99 9
ANNUITY BENEFIT
OVERVIEW
Single Purchase The Single Purchase Payment is shown on the Specifications Page. No
Payment additional payments may be made.
Net Payment The Net Payment is equal to the Single Purchase Payment reduced by any
applicable Premium Tax. The Net Payment is allocated as shown on the
Specifications Page.
Income Options The Income Option you selected is shown on the Specifications Page. Income
Options may be Fixed, Variable or combination Fixed and Variable.
The Fixed Income Option provides a guaranteed amount of income. The Fixed
Income Option is funded through the General Account.
The Variable Income Option provides income which will vary over time. The
investment performance of the selected Sub-Accounts causes changes in Annuity
Unit Values, which result in fluctuating payments.
A combination Fixed and Variable Income Option provides a portion of income that
is guaranteed in amount and a portion that will vary in amount.
Any portion of your Net Payment allocated to the Fixed Income Option
will always remain allocated to the Fixed Income Option. Similarly, any
portion of your Net Payment allocated to the Variable Income Option will always
remain allocated to the Variable Income Option, but you can reallocate this
variable portion of your contract among the various Sub-Accounts. See the
"Transfers" provision for additional information.
Payment of Annuity Annuity Payments are paid to you. By Request you may direct that
Payments payments be made to another person, persons or entity.
FORM A3029-99 10
VARIABLE INCOME OPTIONS
Assumed Investment The Assumed Investment Return ("AIR") is used to calculate the initial variable
Return annuity payment and to determine how the payment will change over time in
response to the investment performance of the selected Sub-Accounts. If the
actual performance of any selected Sub-Account (as measured by the Net
Investment Factor) is equal to the AIR, the annuity payment attributable to that
Sub-Account will be constant. If the actual performance is greater than the
AIR, the annuity payment will increase. If the actual performance is less than
the AIR, the annuity payment will decrease.
Net Investment Factor The Net Investment Factor measures the investment
performance of a Sub-Account from one Valuation Period to the next. This
factor is equal to 1.000000 plus the result (which may be positive or
negative) from dividing (a) by (b) and subtracting (c) and (d) where:
(a) is the investment income of a Sub-Account
for the Valuation Period, including
realized or unrealized capital gains and
losses during the Valuation Period,
adjusted for provisions made for taxes, if any;
(b) is the value of that Sub-Account's assets at
the beginning of the Valuation Period;
(c) is the Mortality and Expense Risk Charge
applicable to the current Valuation
Period (see Specifications Page)
plus any adjustment for an optional feature;
and
(d) is the Administrative Charge applicable to
the current Valuation Period (see Specifications Page).
We guarantee that the amount of each variable annuity payment will not be
affected by changes in our mortality and expense experience. We assume the risk
that actual mortality experience and expenses may exceed the amounts provided
under the contract. We guarantee that the mortality and expense risk and the
administrative charges will not be increased. Subject to applicable State
and federal laws, these charges may be decreased or the method used to
determine the Net Investment Factor may be changed.
FORM A3029-99 11
Annuity Unit Values A Sub-Account Annuity Unit Value on any Valuation Date is equal to
its value on the preceding Valuation Date multiplied by the product of:
(a) a discount factor equivalent to the Assumed Investment
Return and
(b) the Net Investment Factor of the
Sub-Account for the applicable Valuation
Period.
The value of an Annuity Unit as of any
date other than a Valuation Date is
equal to its value as of the preceding
Valuation Date.
Determination of the We have annuity option rates that determine the dollar amount of the first
Number of Annuity periodic payment under each Variable Income Option for each $1,000 of Net
Units Payment. We calculate this amount assuming there is no change in the Annuity
Unit Value. We then divide the amount of the first annuity payment attributable
to a particular Sub-Account by the Annuity Unit Value of that Sub-Account
to determine the number of Annuity Units. This number of Annuity Units
remains fixed under all annuity benefit options except the Joint Life Annuity
with a Survivor Benefit Options that reduce the number of Annuity Units upon
the first death. However, the number of variable annuity units under any Annuity
Benefit Option could change if transfers or withdrawals are made.
Dollar Amount of First The dollar amount of the first variable annuity payment will equal the number of
Variable Annuity Payment Annuity Units of each Sub-Account multiplied by the value of
an Annuity Unit of that Sub-Account on the applicable Valuation Date. The
benefit of any optional feature will be taken into account.
Dollar Amount of Subsequent The dollar amount of each subsequent variable annuity payment will vary
Variable Annuity Payments with the Annuity Unit Value of the selected Sub-Account(s) on certain dates.
The dollar amount of variable annuity payments remains level until the Date of
First Change and within each Change Frequency cycle. On the Date of First
Change and as of the start of each Change Frequency cycle the dollar amount
of the variable annuity payment is determined by multiplying the number of
Annuity Units of each Sub-Account by the Annuity Unit Value of that Sub-Account
on the applicable Valuation Date. The benefit of any optional feature will be
taken into account.
FORM A3029-99 12
Transfers You may make transfers among the Sub-Accounts by Request to us. Transfers
may be made (a) before the Annuity Income Date and before the death of an
Owner or an Annuitant; or (b) after the Annuity Income Date as long as annuity
payments are payable under the Annuity Benefit Option selected.
Transfers may increase or decrease the number of Annuity Units in each
subsequent payment.
There is no charge for the first twelve transfers per Contract Year. A transfer
charge of up to $25 may be imposed on each additional transfer.
We reserve the right to establish and impose reasonable rules restricting
transfers. All transfers are subject to our consent.
FORM A3029-99 13
WITHDRAWALS
You have the right, based on the Annuity Benefit Option selected, to make
withdrawals. Withdrawals may be made (a) before the Annuity Income Date and
before the death of an Owner or an Annuitant; or (b) after the Annuity
Income Date and as long as annuity payments are payable under the Annuity
Benefit Option selected. If the Death Benefit is applied under an Annuity
Benefit Option, withdrawals may also be made in accordance with this provision.
Amounts withdrawn that were applied under a Variable Income Option will be
paid within 7 days of the date we receive your Request. We reserve the
right to delay payments subject to applicable laws, rules and regulations
governing variable annuities.
Amounts withdrawn that were applied under a Fixed Income Option will
normally be paid within 7 days of the date we receive your Request. We may
defer payment for up to six months from the receipt date. If deferred for 30
days or more, the amount payable will be credited interest at a rate of at least
3% or the appropriate rate mandated by the State.
Your Request must indicate the dollar amount to be paid and we will withdraw
that amount on a Pro-Rata basis.
One Request for withdrawal under a provision(s) may be made each calendar
year:
Payment Withdrawal Each calendar year, you can request a withdrawal up to an amount equal to:
Amount Option
(a) the Payment Withdrawal Amount (see
Specifications Page) multiplied by the value
of an annuity payment, if one were to be paid,
on the date we receive your Request (if the
withdrawal is taken prior to the Annuity
Income Date), or
(b) the Payment Withdrawal Amount (see
Specifications Page) multiplied by the
previous annuity payment (if the
withdrawal is taken after the Annuity
Income Date).
Each withdrawal proportionately reduces the number of Annuity Units (for
Variable Income Options) and/or the dollar amount (for Fixed Income Options)
of each future annuity payment. The proportionate reduction is calculated by
multiplying the number of Annuity Units or the dollar amount (whichever is
applicable) of each future annuity payment by the following:
FORM A3029-99 14
Amount of the variable or fixed withdrawal
--------------------------------------------
Present Value of all remaining variable or fixed annuity
payments immediately prior to the withdrawal
Present Value Over the life of the contract when there are remaining guaranteed annuity
Withdrawal Option payments, you may request withdrawals which represent a percentage of the
Present Value of those remaining guaranteed payments.
Each withdrawal proportionately reduces any remaining guaranteed payments (for
Variable Income Options) and/or the dollar amount of each future annuity
payment (for Fixed Income Options). The proportionate reduction is calculated by
multiplying the number of Annuity Units or the dollar amount (whichever is
applicable) of each future annuity payment by the following:
Amount of the variable or fixed withdrawal
------------------------------------------
Present Value of all remaining variable or fixed guaranteed annuity
payments immediately prior to the withdrawal
Whenever a withdrawal is taken under this provision, we record the percentage
withdrawn. (See proportionate reduction calculation above.) The total percentage
withdrawn over the life of the contract cannot exceed the Present Value
Withdrawal Amount (see Specifications Page).
If an Annuitant is still living after the guaranteed payments have been paid,
the number of Annuity Units (for Variable Income Options) or dollars (for
Fixed Income Options) will increase to the number of Annuity Units/dollars
payable prior to any Present Value Withdrawals, adjusted upon the death of
the first Annuitant, if applicable, or for transfers, or for any withdrawals
taken under the Payment Withdrawal Amount Option.
FORM A3029-99 15
Present Value For a variety of purposes, it is at times necessary to determine the Present
Value of either all future annuity payments or of future guaranteed
annuity payments. Present Values are calculated based on the Mortality
Table used by us to determine your benefit (see Specifications Page),
male, female or unisex rates as appropriate, and the interest rate (for
Fixed Income Options) or AIR (for Variable Income Options) used to
determine the annuity payments increased by the following adjustments:
Adjustment
Death of Annuitant 0.00%
Withdrawals
5 or more years after Issue Date 0.00%
Within 5 years of Issue Date:
15 or more years of annuity payments being valued 1.00%
10-14 years of payments being valued 1.50%
Less than 10 years of payments being valued 2.00%
Determination of Contract Value* 0.00%
* If an optional feature, was selected, annuity payments used in determining
this Present Value will be the amount that would have been payable had you not
selected the optional feature.
FORM A3029-99 16
DEATH OF OWNER OR ANNUITANT
BEFORE THE ANNUITY INCOME DATE
Death Benefit If an Owner or an Annuitant dies, we will pay a Death Benefit equal
to the Contract Value. The Contract Value will be determined as of the
Effective Valuation Date.
The Death Benefit will be paid to the Owner of the contract. If there is no
Owner or Joint Owner, we will pay the Death Benefit to the Beneficiary.
Payment of the Death Unless You have specified otherwise, the Death Benefit will be paid within 7
days of the Effective Valuation Date. Alternatively, the person entitled
to the Death Benefit may, by Request, elect to receive an annuity over
his or her life expectancy (or over a period not extending beyond such
life expectancy), with distributions beginning within one year from the
date of death.
If the sole Beneficiary is the deceased Owner's spouse, the Beneficiary may
elect to continue the contract as the Owner and Annuitant. As of the date of
such election, annuity payments will be adjusted to reflect any change of
Annuitant and Annuity Income Date. The new Annuity Income Date must be within
twelve months of the Issue Date (see the Specifications Page). Any subsequent
spouse of the new Owner, if named as the Beneficiary, may not continue this
contract.
AFTER THE ANNUITY INCOME DATE
Remaining Annuity If the Owner or the Annuitant dies, we will pay remaining annuity payments, if any,
Payments in accordance with the terms of the Annuity Benefit Option selected.
Any remaining annuity payments will be paid to the Owner of the contract. If
there is no Owner or Joint Owner, then the Beneficiary will receive the
payments and become the Owner of the contract.
Lump Sum Option The Beneficiary may elect to receive the Present Value of any
remaining payments in one lump sum.
FORM A3029-99 17
GENERAL PROVISIONS
Entire Contract The entire contract consists of this contract, any application attached
at issue, Specifications page and endorsements.
Misstatement of Age If the age or sex of an individual is misstated, we will adjust all benefits
Or Sex payable to that which would be available at the correct age or sex. Any
underpayments already made by us will be paid immediately. Any overpayments will
be deducted from future annuity payments.
Failure to Notify Company After the Annuity Income Date and once notified of the Annuitant's death,
of Annuitant Death we reserve the right to recover any overpaid annuity payments.
Modifications Only the President or Vice President of the Company may modify or waive any
provisions of this contract. Agents or Brokers are not authorized to do so.
Incontestability We will not contest this contract.
Minimums All values and benefits available under this contract equal or exceed those
required by the State in which the contract is delivered.
Annual Report We will send you an annual report of the Sub-Accounts and any other
notices, reports or documents required by law to be delivered to you.
Addition, Deletion, or We reserve the right, subject to compliance with applicable law, to add to,
Substitution of delete from, or substitute for the shares of a Fund that are held by the
Investments Sub-Accounts or that the Sub-Accounts may purchase. We also reserve the right
to eliminate the shares of any Fund no longer available for investment or if we
believe further investment in the Fund is no longer appropriate for the
purposes of the Sub-Accounts.
We will not substitute shares attributable to any interest in a Sub-Account without
notice to you and prior approval of the Securities and Exchange Commission as
required by the Investment Company Act of 1940. This will not prevent the Variable
Account from purchasing other securities for other series or classes of contracts, or
from permitting a conversion between series or classes of contracts on the basis of
requests made by you.
FORM A3029-99 18
We reserve the right, subject to compliance with applicable laws, to establish
additional Separate Accounts and Sub-Accounts and to make them available to any
class or series of contracts as we consider appropriate. Each new Separate Account
or Sub-Account will invest in a new investment company, or in shares of another
open-end investment company, or such other investments as may be permitted under
applicable law. We also reserve the right to eliminate or combine existing
Sub-Accounts and to transfer the assets of any Sub-Accounts to any other Sub-Accounts.
In the event of any substitution or change, we may, by appropriate notice, make such
changes in this and other contracts as may be necessary or appropriate to reflect the
substitution or change. If we consider it to be in the best interests of the owners,
the Variable Account or any Sub-Account may be operated as a management company under
the Investment Company Act of 1940 or in any other form permitted by law, or may be
deregistered under the Act in the event registration is no longer required, or may be
combined with our other accounts.
Changes in Law We reserve the right to make any changes to provisions of the contract to comply with,
or give you the benefit of, any federal or State statute, rule, or regulation.
Change of Name Subject to compliance with applicable law, We reserve the right to change the names of
the Variable Account or the Sub-Accounts.
Federal Tax The Variable Account is not currently subject to tax, but we reserve the right to
Considerations assess a charge for taxes if the Variable Account becomes subject to tax.
Splitting of Units We reserve the right to split the value of a unit, either to increase or decrease
the number of units. Any splitting of units will have no material effect on the
benefits, provisions or investment return of this contract or upon you, the Annuitant,
any Beneficiary, or us.
Insulation of Separate The investment performance of Separate Account assets is determined separately from
Account our other assets. The assets of a Separate Account equal to the reserves and
liabilities of the contracts supported by the account will not be charged with
liabilities from any other business that we may conduct.
FORM A3029-99 19
Single Payment Immediate Variable and Fixed Annuity
Annuity Payments Payable on the Annuity Income Date
Death Benefit Payable if an Owner or an
Annuitant Dies prior to Annuity Income Date
This contract does not participate in the profits or surplus of the Company
FORM A3029-99
PLEASE READ THIS CONTRACT CAREFULLY
IMPORTANT: THE INITIAL INTEREST RATE, ALTHOUGH GUARANTEED TO BE A MINIMUM, IS
GUARANTEED ONLY FOR A LIMITED PERIOD OF TIME.
Annuity payments and other values provided by this contract under the Variable
Income Options may increase or decrease and are not guaranteed as to fixed
dollar amount.
RIGHT TO EXAMINE CONTRACT
You may return this contract within 90 days after you have received it (the
"Free Look Period"). It can be mailed or delivered either to us or the
representative who sold it. If you return the contract, we will pay to you the
Contract Value on the date the contract is returned to us plus any premium tax
deducted on the Issue Date. This amount may be more or less than the Single
Purchase Payment.
ALLMERICA FINANCIAL LIFE INSURANCE AND ANNUITY COMPANY
Home Office: Dover, Delaware
Principal Office: 000 Xxxxxxx Xxxxxx, Xxxxxxxxx, Xxxxxxxxxxxxx 00000
Phone Number: 0-000-000-0000
This is a legal contract between you and the Company and is issued in
consideration of the Single Purchase Payment shown on the Specifications page.
The Net Payment may be allocated to the Fixed Income Option or the Variable
Income Option or a combination of both. If you select the Variable Income
Option, you can allocate the Net Payment among the Variable Sub-Accounts.
Single Payment Immediate Variable and Fixed Annuity
Annuity Payments Payable on the Annuity Income Date
Death Benefit Payable if an Owner or an
Annuitant Dies prior to Annuity Income Date
This contract does not participate in the profits or surplus of the Company
FORM A3029.FL-99
TABLE OF CONTENTS
SPECIFICATIONS............................................................... 3
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION................................... 5
DEFINITIONS.................................................................. 6
OWNER, ANNUITANT AND BENEFICIARY............................................. 8
ANNUITY BENEFIT.............................................................. 10
OVERVIEW........................................................ 10
VARIABLE INCOME OPTIONS......................................... 11
WITHDRAWALS..................................................... 14
DEATH OF OWNER OR ANNUITANT.................................................. 17
BEFORE THE ANNUITY INCOME DATE.................................. 17
AFTER THE ANNUITY INCOME DATE................................... 17
GENERAL PROVISIONS........................................................... 18
Annuities are not FDIC insured. Annuities are not obligations of the financial
institution. The financial institution does not guarantee performance by the
insurer issuing the annuity.
FORM A3029.FL-99 2
PLEASE READ THIS CONTRACT CAREFULLY
IMPORTANT: THE INITIAL INTEREST RATE, ALTHOUGH GUARANTEED TO BE A MINIMUM, IS
GUARANTEED ONLY FOR A LIMITED PERIOD OF TIME.
Annuity payments and other values provided by this contract under the Variable
Income Options may increase or decrease and are not guaranteed as to fixed
dollar amount.
RIGHT TO EXAMINE CONTRACT
You may return this contract within 90 days after you have received it. It can
be mailed or delivered either to us or the representative who sold it. If you
return the contract within 10 days after you have received it ("the Free Look
Period"), we will refund the Single Purchase Payment less the total amount of
all annuity payments made or withdrawals taken. If you return the contract after
the expiration of the "Free Look Period" but within 90 days after the Issue
Date, we will pay to you the Contract Value on the date the contract is returned
to us plus any premium tax deducted on the Issue Date.
ALLMERICA FINANCIAL LIFE INSURANCE AND ANNUITY COMPANY
Home Office: Dover, Delaware
Principal Office: 000 Xxxxxxx Xxxxxx, Xxxxxxxxx, Xxxxxxxxxxxxx 00000
Phone Number: 0-000-000-0000
This is a legal contract between you and the Company and is issued in
consideration of the Single Purchase Payment shown on the Specifications page.
The Net Payment may be allocated to the Fixed Income Option or the Variable
Income Option or a combination of both. If you select the Variable Income
Option, you can allocate the Net Payment among the Variable Sub-Accounts.
Single Payment Immediate Variable and Fixed Annuity
Annuity Payments Payable on the Annuity Income Date
Death Benefit Payable if an Owner or an
Annuitant Dies prior to Annuity Income Date
This contract does not participate in the profits or surplus of the Company
FORM A3029.FL-99
TABLE OF CONTENTS
SPECIFICATIONS............................................................... 3
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION................................... 5
DEFINITIONS.................................................................. 6
OWNER, ANNUITANT AND BENEFICIARY............................................. 8
ANNUITY BENEFIT.............................................................. 10
OVERVIEW........................................................ 10
VARIABLE INCOME OPTIONS......................................... 11
WITHDRAWALS..................................................... 14
DEATH OF OWNER OR ANNUITANT.................................................. 17
BEFORE THE ANNUITY INCOME DATE.................................. 17
AFTER THE ANNUITY INCOME DATE................................... 17
GENERAL PROVISIONS........................................................... 18
Annuities are not FDIC insured. Annuities are not obligations of the financial
institution. The financial institution does not guarantee performance by the
insurer issuing the annuity.
FORM A3029.FL-99 2
PLEASE READ THIS CONTRACT CAREFULLY
Annuity payments and other values provided by this contract under the Variable
Income Options may increase or decrease and are not guaranteed as to fixed
dollar amount.
RIGHT TO EXAMINE CONTRACT
You may return this contract within 90 days after you have received it (the
"Free Look Period"). It can be mailed or delivered either to us or the
representative who sold it. If you return the contract, we will pay to you the
Contract Value on the date the contract is returned to us plus any premium tax
deducted on the Issue Date. This amount may be more or less than the Single
Purchase Payment.
ALLMERICA FINANCIAL LIFE INSURANCE AND ANNUITY COMPANY
Home Office: Dover, Delaware
Principal Office: 000 Xxxxxxx Xxxxxx, Xxxxxxxxx, Xxxxxxxxxxxxx 00000
Phone Number: 0-000-000-0000
This is a legal contract between you and the Company and is issued in
consideration of the Single Purchase Payment shown on the Specifications page.
The Net Payment may be allocated to the Fixed Income Option or the Variable
Income Option or a combination of both. If you select the Variable Income
Option, you can allocate the Net Payment among the Variable Sub-Accounts.
Single Payment Immediate Variable and Fixed Annuity
Annuity Payments Payable on the Annuity Income Date
Death Benefit Payable if an Owner or an
Annuitant Dies prior to Annuity Income Date
This contract does not participate in the profits or surplus of the Company
FORM A3029.FL-99
TABLE OF CONTENTS
SPECIFICATIONS............................................................... 3
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION................................... 5
DEFINITIONS.................................................................. 6
OWNER, ANNUITANT AND BENEFICIARY............................................. 8
ANNUITY BENEFIT.............................................................. 10
OVERVIEW........................................................ 10
VARIABLE INCOME OPTIONS......................................... 11
WITHDRAWALS..................................................... 14
DEATH OF OWNER OR ANNUITANT.................................................. 17
BEFORE THE ANNUITY INCOME DATE.................................. 17
AFTER THE ANNUITY INCOME DATE................................... 17
GENERAL PROVISIONS........................................................... 18
Annuities are not FDIC insured. Annuities are not obligations of the financial
institution. The financial institution does not guarantee performance by the
insurer issuing the annuity.
FORM A3029.FL-99 2
PLEASE READ THIS CONTRACT CAREFULLY
Annuity payments and other values provided by this contract under the Variable
Income Options may increase or decrease and are not guaranteed as to fixed
dollar amount.
RIGHT TO EXAMINE CONTRACT
You may return this contract within 90 days after you have received it. It can
be mailed or delivered either to us or the representative who sold it. If you
return the contract within 10 days after you have received it ("the Free Look
Period"), we will refund the Single Purchase Payment less the total amount of
all annuity payments made or withdrawals taken. If you return the contract after
the expiration of the "Free Look Period" but within 90 days after the Issue
Date, we will pay to you the Contract Value on the date the contract is returned
to us plus any premium tax deducted on the Issue Date.
ALLMERICA FINANCIAL LIFE INSURANCE AND ANNUITY COMPANY
Home Office: Dover, Delaware
Principal Office: 000 Xxxxxxx Xxxxxx, Xxxxxxxxx, Xxxxxxxxxxxxx 00000
Phone Number: 0-000-000-0000
This is a legal contract between you and the Company and is issued in
consideration of the Single Purchase Payment shown on the Specifications page.
The Net Payment may be allocated to the Fixed Income Option or the Variable
Income Option or a combination of both. If you select the Variable Income
Option, you can allocate the Net Payment among the Variable Sub-Accounts.
Single Payment Immediate Variable and Fixed Annuity
Annuity Payments Payable on the Annuity Income Date
Death Benefit Payable if an Owner or an
Annuitant Dies prior to Annuity Income Date
This contract does not participate in the profits or surplus of the Company
FORM A3029.FL-99
TABLE OF CONTENTS
SPECIFICATIONS............................................................... 3
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION................................... 5
DEFINITIONS.................................................................. 6
OWNER, ANNUITANT AND BENEFICIARY............................................. 8
ANNUITY BENEFIT.............................................................. 10
OVERVIEW........................................................ 10
VARIABLE INCOME OPTIONS......................................... 11
WITHDRAWALS..................................................... 14
DEATH OF OWNER OR ANNUITANT.................................................. 17
BEFORE THE ANNUITY INCOME DATE.................................. 17
AFTER THE ANNUITY INCOME DATE................................... 17
GENERAL PROVISIONS........................................................... 18
Annuities are not FDIC insured. Annuities are not obligations of the financial
institution. The financial institution does not guarantee performance by the
insurer issuing the annuity.
FORM A3029.FL-99 2
SPECIFICATIONS
Contract Type: Non-qualified Single Purchase Payment Amount:
Contract Number: zz00600000 Net Payment:
Owner: Xxxx Xxx Owner's Date of Birth: 10/25/1960
Joint Owner: Xxxx Xxx Joint Owner's Date of Birth: 07/12/1960
Annuitant: Xxxx Xxx Xxxxxxxxx's Date of Birth: 03/19/1945
Joint Annuitant: Xxxxxxx Xxx Joint Annuitant's Date of Birth: 08/20/1954
Annuitant's Sex: Female Payee: Xxxx Xxx
Joint Annuitant's Sex: Male Payee's Address: 0 Xxxx Xx, Xxxxxxxx, XXX
Primary Beneficiary: Surviving Joint Owner, if any
1st Contingent Beneficiary(ies): Xxxxxxx Xxx
2nd Contingent Beneficiary(ies): Xxxx Xxx
Issue Date: 04/01/1999
Annuity Income Date: 10/01/1999
Annuity Benefit Option: Joint Life Annuity with a Survivor Benefit Option (See page 5)
Survivor Benefit Percentage: 50%
Frequency of Annuity Payments: Monthly
Mortality Table: Annuity 2000
Percentage under a Fixed Income Option: 30%
Dollar Amount of Fixed Income: $
Percentage under a Variable Income Option: 70%
Assumed Investment Return: 5%
Change Frequency: Monthly
Date of First Change: xx/xx/xxxx
Income Option Rate: 4.5
Optional Feature:
The Ratchet:
Initial Ratchet Amount: $100
Ratchet Maximum Benefit Increase Percentage: 10%
If you had not selected this feature, the Income Option Rate above would have been 5.0.
The Floor:
Floor Amount: $100
If you had not selected this feature, the Income Option Rate above would have been 5.0.
FORM A8029-99 3
SPECIFICATIONS (CONTINUED)
Owner: Xxxx Xxx Contract Number: zz00600000
Joint Owner: Xxxx Xxx
Single Purchase Amount: $25,000.00
Payment Withdrawal Amount: 10 times the previous annuity payment.
But not more than the remaining guaranteed payments.
Present Value Withdrawal Amount: 75% of Present Value of remaining guaranteed annuity payments.
Mortality and Expense Risk Charge: 1.25% on an annual basis of the daily value of the Sub-Account assets.
Administrative Charge: .20% on an annual basis of the daily value of the Sub-Account assets.
Variable Allocation of Net Payment on Issue Date:
Sub-Account Name Percentage of Net Payment Number of Units
---------------- ------------------------- ---------------
Select Aggr. Growth
Select Capital Appr.
Select Value Opp.
Select Emerging Markets
Select Int'l Equity
DGPF Int'l Equity Series
Fidelity VIP Overseas
X. Xxxx Price Int'l
Select Growth
Select Strategic Growth
Growth Fund
Fidelity VIP Growth
Equity Index Fund
Select Gr. & Inc.
Fidelity VIP Eq. Inc.
Fidelity VIP Asset Mgr
Fidelity VIP High Inc
Investment Grade Income Fund
Government Bond Fund
Allmerica Money Market
FORM A8029-99 4
PLEASE READ THIS CONTRACT CAREFULLY
Annuity payments and other values provided by this contract under the Variable
Income Options may increase or decrease and are not guaranteed as to fixed
dollar amount.
RIGHT TO EXAMINE CONTRACT
The Owner may cancel this contract by returning it to the Company or one of its
authorized representatives within twenty days after receipt. If returned, the
Company will refund gross payments.
ALLMERICA FINANCIAL LIFE INSURANCE AND ANNUITY COMPANY
Home Office: Dover, Delaware
Principal Office: 000 Xxxxxxx Xxxxxx, Xxxxxxxxx, Xxxxxxxxxxxxx 00000
Phone Number: 0-000-000-0000
This is a legal contract between you and the Company and is issued in
consideration of the Single Purchase Payment shown on the Specifications page.
The Net Payment may be allocated to the Fixed Income Option or the Variable
Income Option or a combination of both. If you select the Variable Income
Option, you can allocate the Net Payment among the Variable Sub-Accounts.
Single Payment Immediate Variable and Fixed Annuity
Annuity Payments Payable on the Annuity Income Date
Death Benefit Payable if an Owner or an
Annuitant Dies prior to Annuity Income Date
This contract does not participate in the profits or surplus of the Company
FORM A3029-99
TABLE OF CONTENTS
SPECIFICATIONS.............................................................. 3
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION.................................. 5
DEFINITIONS................................................................. 6
OWNER, ANNUITANT AND BENEFICIARY............................................ 8
ANNUITY BENEFIT............................................................. 10
OVERVIEW....................................................... 10
VARIABLE INCOME OPTIONS........................................ 11
WITHDRAWALS.................................................... 14
DEATH OF OWNER OR ANNUITANT................................................. 17
BEFORE THE ANNUITY INCOME DATE................................. 17
AFTER THE ANNUITY INCOME DATE.................................. 17
GENERAL PROVISIONS.......................................................... 18
FORM A3029-99 2
PLEASE READ THIS CONTRACT CAREFULLY
Annuity payments and other values provided by this contract under the Variable
Income Options may increase or decrease and are not guaranteed as to fixed
dollar amount.
RIGHT TO EXAMINE CONTRACT
The Owner may cancel this contract by returning it to the Company or one of its
authorized representatives within twenty days after receipt. If returned, the
Company will refund gross payments.
ALLMERICA FINANCIAL LIFE INSURANCE AND ANNUITY COMPANY
Home Office: Dover, Delaware
Principal Office: 000 Xxxxxxx Xxxxxx, Xxxxxxxxx, Xxxxxxxxxxxxx 00000
Phone Number: 0-000-000-0000
This is a legal contract between you and the Company and is issued in
consideration of the Single Purchase Payment shown on the Specifications page.
The Net Payment may be allocated to the Fixed Income Option or the Variable
Income Option or a combination of both. If you select the Variable Income
Option, you can allocate the Net Payment among the Variable Sub-Accounts.
Single Payment Immediate Variable and Fixed Annuity
Annuity Payments Payable on the Annuity Income Date
Death Benefit Payable if an Owner or an
Annuitant Dies prior to Annuity Income Date
This contract does not participate in the profits or surplus of the Company
FORM A3029.4-99
TABLE OF CONTENTS
SPECIFICATIONS............................................................... 3
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION................................... 5
DEFINITIONS.................................................................. 6
OWNER, ANNUITANT AND BENEFICIARY............................................. 8
ANNUITY BENEFIT.............................................................. 10
OVERVIEW........................................................ 10
VARIABLE INCOME OPTIONS......................................... 11
WITHDRAWALS..................................................... 14
DEATH OF OWNER OR ANNUITANT.................................................. 17
BEFORE THE ANNUITY INCOME DATE.................................. 17
AFTER THE ANNUITY INCOME DATE................................... 17
GENERAL PROVISIONS........................................................... 18
FORM A3029-99 2
PLEASE READ THIS CONTRACT CAREFULLY
Annuity payments and other values provided by this contract under the Variable
Income Options may increase or decrease and are not guaranteed as to fixed
dollar amount.
RIGHT TO EXAMINE CONTRACT
You may return this contract within 90 days after you have received it (the
"Free Look Period"). It can be mailed or delivered either to us or the
representative who sold it. If you return the contract, we will pay to you the
Contract Value on the date the contract is returned to us plus any premium tax
deducted on the Issue Date. This amount may be more or less than the Single
Purchase Payment.
FIRST ALLMERICA FINANCIAL LIFE INSURANCE COMPANY
Home Office: Dover, Delaware
Principal Office: 000 Xxxxxxx Xxxxxx, Xxxxxxxxx, Xxxxxxxxxxxxx 00000
Phone Number: 0-000-000-0000
This is a legal contract between you and the Company and is issued in
consideration of the Single Purchase Payment shown on the Specifications page.
The Net Payment may be allocated to the Fixed Income Option or the Variable
Income Option or a combination of both. If you select the Variable Income
Option, you can allocate the Net Payment among the Variable Sub-Accounts.
Single Payment Immediate Variable and Fixed Annuity
Annuity Payments Payable on the Annuity Income Date
Death Benefit Payable if an Owner or an
Annuitant Dies prior to Annuity Income Date
This contract does not participate in the profits or surplus of the Company
FORM A3029-99-GRC
TABLE OF CONTENTS
SPECIFICATIONS............................................................... 3
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION................................... 5
DEFINITIONS.................................................................. 6
OWNER, ANNUITANT AND BENEFICIARY............................................. 8
ANNUITY BENEFIT.............................................................. 10
OVERVIEW........................................................ 10
VARIABLE INCOME OPTIONS......................................... 11
WITHDRAWALS..................................................... 14
DEATH OF OWNER OR ANNUITANT.................................................. 17
BEFORE THE ANNUITY INCOME DATE.................................. 17
AFTER THE ANNUITY INCOME DATE................................... 17
GENERAL PROVISIONS........................................................... 18
FORM A3029-99 2
PLEASE READ THIS CONTRACT CAREFULLY
Annuity payments and other values provided by this contract under the Variable
Income Options may increase or decrease and are not guaranteed as to fixed
dollar amount.
RIGHT TO EXAMINE CONTRACT
You may return this contract within 90 days after you have received it. It can
be mailed or delivered either to us or the representative who sold it. If you
return the contract within 10 days after you have received it ("the Free Look
Period"), we will refund the Single Purchase Payment less the total amount of
all annuity payments made or withdrawals taken. If you return the contract after
the expiration of the "Free Look Period" but within 90 days after the Issue
Date, we will pay to you the Contract Value on the date the contract is returned
to us plus any premium tax deducted on the Issue Date.
FIRST ALLMERICA FINANCIAL LIFE INSURANCE COMPANY
Home Office: Dover, Delaware
Principal Office: 000 Xxxxxxx Xxxxxx, Xxxxxxxxx, Xxxxxxxxxxxxx 00000
Phone Number: 0-000-000-0000
This is a legal contract between you and the Company and is issued in
consideration of the Single Purchase Payment shown on the Specifications page.
The Net Payment may be allocated to the Fixed Income Option or the Variable
Income Option or a combination of both. If you select the Variable Income
Option, you can allocate the Net Payment among the Variable Sub-Accounts.
Single Payment Immediate Variable and Fixed Annuity
Annuity Payments Payable on the Annuity Income Date
Death Benefit Payable if an Owner or an
Annuitant Dies prior to Annuity Income Date
This contract does not participate in the profits or surplus of the Company
FORM A3029-99-GRC
TABLE OF CONTENTS
SPECIFICATIONS............................................................... 3
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION................................... 5
DEFINITIONS.................................................................. 6
OWNER, ANNUITANT AND BENEFICIARY............................................. 8
ANNUITY BENEFIT.............................................................. 10
OVERVIEW........................................................ 10
VARIABLE INCOME OPTIONS......................................... 11
WITHDRAWALS..................................................... 14
DEATH OF OWNER OR ANNUITANT.................................................. 17
BEFORE THE ANNUITY INCOME DATE.................................. 17
AFTER THE ANNUITY INCOME DATE................................... 17
GENERAL PROVISIONS........................................................... 18
FORM A3029-99 2
PLEASE READ THIS CONTRACT CAREFULLY
Annuity payments and other values provided by this contract under the Variable
Income Options may increase or decrease and are not guaranteed as to fixed
dollar amount.
RIGHT TO EXAMINE CONTRACT
You may return this contract within 90 days after you have received it (the
"Free Look Period"). It can be mailed or delivered either to us or the
representative who sold it. If you return the contract, we will pay to you the
Contract Value on the date the contract is returned to us plus any premium tax
deducted on the Issue Date. This amount may be more or less than the Single
Purchase Payment.
If the refund is not paid within thirty days from the date the contract is
received by the Company or its authorized representative, the amount will be
increased by ten percent (10%).
ALLMERICA FINANCIAL LIFE INSURANCE AND ANNUITY COMPANY
Home Office: Dover, Delaware
Principal Office: 000 Xxxxxxx Xxxxxx, Xxxxxxxxx, Xxxxxxxxxxxxx 00000
Phone Number: 0-000-000-0000
This is a legal contract between you and the Company and is issued in
consideration of the Single Purchase Payment shown on the Specifications page.
The Net Payment may be allocated to the Fixed Income Option or the Variable
Income Option or a combination of both. If you select the Variable Income
Option, you can allocate the Net Payment among the Variable Sub-Accounts.
Single Payment Immediate Variable and Fixed Annuity
Annuity Payments Payable on the Annuity Income Date
Death Benefit Payable if an Owner or an
Annuitant Dies prior to Annuity Income Date
This contract does not participate in the profits or surplus of the Company
FORM A3029.WA-99
TABLE OF CONTENTS
SPECIFICATIONS............................................................... 3
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION................................... 5
DEFINITIONS.................................................................. 6
OWNER, ANNUITANT AND BENEFICIARY............................................. 8
ANNUITY BENEFIT.............................................................. 10
OVERVIEW........................................................ 10
VARIABLE INCOME OPTIONS......................................... 11
WITHDRAWALS..................................................... 14
DEATH OF OWNER OR ANNUITANT.................................................. 17
BEFORE THE ANNUITY INCOME DATE.................................. 17
AFTER THE ANNUITY INCOME DATE................................... 17
GENERAL PROVISIONS........................................................... 18
FORM A3029-99 2
PLEASE READ THIS CONTRACT CAREFULLY
Annuity payments and other values provided by this contract under the Variable
Income Options may increase or decrease and are not guaranteed as to fixed
dollar amount.
RIGHT TO EXAMINE CONTRACT
You may return this contract within 90 days after you have received it. It can
be mailed or delivered either to us or the representative who sold it. If you
return the contract within 10 days after you have received it ("the Free Look
Period"), we will refund the Single Purchase Payment less the total amount of
all annuity payments made or withdrawals taken. If you return the contract after
the expiration of the "Free Look Period" but within 90 days after the Issue
Date, we will pay to you the Contract Value on the date the contract is returned
to us plus any premium tax deducted on the Issue Date.
If the refund is not paid within thirty days from the date the contract is
received by the Company or its authorized representative, the amount will be
increased by ten percent (10%).
ALLMERICA FINANCIAL LIFE INSURANCE AND ANNUITY COMPANY
Home Office: Dover, Delaware
Principal Office: 000 Xxxxxxx Xxxxxx, Xxxxxxxxx, Xxxxxxxxxxxxx 00000
Phone Number: 0-000-000-0000
This is a legal contract between you and the Company and is issued in
consideration of the Single Purchase Payment shown on the Specifications page.
The Net Payment may be allocated to the Fixed Income Option or the Variable
Income Option or a combination of both. If you select the Variable Income
Option, you can allocate the Net Payment among the Variable Sub-Accounts.
Single Payment Immediate Variable and Fixed Annuity
Annuity Payments Payable on the Annuity Income Date
Death Benefit Payable if an Owner or an
Annuitant Dies prior to Annuity Income Date
This contract does not participate in the profits or surplus of the Company
FORM A3029.WA-99
TABLE OF CONTENTS
SPECIFICATIONS............................................................... 3
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION................................... 5
DEFINITIONS.................................................................. 6
OWNER, ANNUITANT AND BENEFICIARY............................................. 8
ANNUITY BENEFIT.............................................................. 10
OVERVIEW........................................................ 10
VARIABLE INCOME OPTIONS......................................... 11
WITHDRAWALS..................................................... 14
DEATH OF OWNER OR ANNUITANT.................................................. 17
BEFORE THE ANNUITY INCOME DATE.................................. 17
AFTER THE ANNUITY INCOME DATE................................... 17
GENERAL PROVISIONS........................................................... 18
FORM A3029-99 2
