FLEXIBLE PAYMENT DEFERRED VARIABLE AND FIXED ANNUITY NON-PARTICIPATING TABLE OF CONTENTSPlease Read • March 1st, 1996 • Sep Acct Va K Execannuity of Allmerica Fin Lfe Ins & Ann Co
Street Address Apt.Allmerica Financial • March 1st, 1996 • Sep Acct Va K Execannuity of Allmerica Fin Lfe Ins & Ann Co
*Attach required additional forms. _______________________________________________________________________________ 5. INITIAL PAYMENT Initial Payment $ _________________________________________ If IRA or SEP-IRA application, the applicant has received a Disclosure Buyer's Guide and this payment is a (check one): / / Rollover / /Trustee to Trustee Transfer / / Regular or SEP-IRA Payment for Tax Year ___________ _______________________________________________________________________________ 6. REPLACEMENT Will the proposed contract replace or change any existing annuity or insurance policy? / / NO / / YES (If yes, list company name and policy number)
