[LOGO] ALLMERICA ALLMERICA FINANCIAL
FINANCIAL-Registered Trademark- LIFE INSURANCE AND 440 Lincoln Street [NEW PRODUCT NAME ]
ANNUITY COMPANY Worcester, MA 01653 VARIABLE LIFE APPLICATION
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[IF SECOND TO DIE PLEASE COMPLETE SUPPLEMENTAL APPLICATION.]
1 INSURED The Person upon whose life this insurance coverage is proposed. 3 BENEFICIARY
_________________________________________________________ The Primary Beneficiary is the person or entity who
First Name Middle Last will receive the policy proceeds. The Contingent
Beneficiary is the person or entity who will receive
_________________________________________________________ the policy proceeds should the Primary Beneficiary not
Street Address Years at this Address survive the insured.
_________________________________________________________ _______________________________________________________
City State Zip Name of Primary Beneficiary Relationship to Insured
(_____)__________________________________________________ _______________________________________________________
Daytime Telephone Number Name of Contingent Beneficiary Relationship to Insured
M/_______D/_______Y/_______ __________________ If the beneficiary is a trust, please specify trust
Date of Birth State of Birth date.
__________________________________ M / / F / / M/_______ D/_______ Y/_______
Social Security Number Sex
4 EMPLOYER
_________________________________________________________
Driver's License Number State _______________________________________________________
Name
_________________________________________________________
Duties/Title _______________________________________________________
Street Address
Date of Hire ____________________________________________
_______________________________________________________
Are you able to perform all of the regular duties of your occupation City State Zip
at the usual place of employment on a full-time work schedule which
is in no way curtailed or altered because of health? / / Yes / / No 5 POLICYOWNER The person or entity exercising the
policy's contractual rights.
Have you smoked one or more cigarettes in the last 12 months?
/ / Yes / / No _______________________________________________________
Name
_______________________________________________________
2 LIFE INSURANCE BENEFIT Street Address
The total amount of coverage applied for is $_______________. _______________________________________________________
City State Zip
Define coverage split between base and term rider.
Social Security or Tax I.D. Number ____________________
Choose one:
Trust Date M/ _____ D/ _____ Y/ _____ (if Trust owned)
/ / ______________% base and ________________% term or
/ / $_____________ base and $________________ term 6 REPLACEMENT FOR OTHER CONTRACTS
I WANT INSURANCE COVERAGE TO BE: (Choose one) WILL THE PROPOSED POLICY REPLACE ANY EXISTING ANNUITY
OR LIFE INSURANCE CONTRACT?
/ / Option 1 Level - Insurance coverage remains constant. / / Yes / / No
If yes, list company name and policy number.
/ / Option 2 Adjustable - Insurance coverage changes with
the value of your policy _______________________________________________________
/ / Option 3 Level - Cash Value Accumulation Test _______________________________________________________
Total life insurance currently in force $______________
7 TELEPHONE ACCESS liability exists and the insurance applied for will
will not effect until the policy is delivered and
Unless I did not accept the Telephone Access privilege, I understand the premium is paid during the lifetime of the
that Allmerica Financial Life Insurance and Annuity Company is authorized proposed insured(s) and then only if the proposed
to honor telephone requests by me, or by individuals authorized by me, to insured(s) has (have) not consulted or been treated
transfer account values among sub-accounts and to change the allocation by any physician or practitioner of any healing art
of my future payments. I also understand that the withdrawal of funds from nor had any tests listed in the application since
my account cannot be transacted by telephone or fax instructions. its completion; but, if the premium is paid prior
to delivery of the policy and a conditional receipt
/ / I DO NOT accept this Telephone Access privilege. is delivered by the representative, insurance will
be effective subject to terms of the conditional
receipt; and (4) No registered representative or
broker is authorized to amend, alter, or modify
8 REMARKS the terms of this agreement.
_____________________________________________________________ ____________________________________________________
Signature of Insured Date
_____________________________________________________________ ____________________________________________________
[Signature of Second Insured]
_____________________________________________________________ ____________________________________________________
Signature of Owners (if other than Insured) Date
____________________________________________________
ACKNOWLEDGMENTS AND SIGNATURES Signed at City State
____________________________________________________
NOTICE TO ARKANSAS/NEW JERSEY/OHIO RESIDENTS ONLY: "Any person who includes Official Title/Capacity
any false or misleading information on an application for an insurance
policy/certificate is subject to criminal and civil penalties." FOR REGISTERED REPRESENTATIVE USE ONLY
NOTICE TO COLORADO/KENTUCKY/MAINE/NEW MEXICO/PENNSYLVANIA/WASHINGTON, D.C. Does the policy applied for replace an existing
RESIDENTS ONLY: "Any person who knowingly and with intent to defraud any annuity or life insurance policy?
insurance company or other person files an application for insurance or / / Yes / / No
state-ment of claim containing any materially false information or conceals If yes, attach replacement forms as required.
for the purpose of misleading, information concerning any fact material As Registered Representative, I certify witnessing
thereto commits a fraudulent insurance act, which is a crime and subjects the signature of the applicant and that the
such person to criminal and civil penalties." information in this application has been accurately
recorded, to the best of my knowledge and belief.
NOTICE TO FLORIDA RESIDENTS ONLY: "Any person who knowingly and with intent
to injure, defraud, or deceive any insurer files a statement of claim or an Based on the information furnished by the owner or
application containing false, incomplete, or misleading information is Insured in this application, I certify that I have
guilty of a felony of the third degree." reasonable grounds for believing the purchase of the
policy applied for is suitable for the Owner. I
I acknowledge receipt of current Prospectuses describing the Allmerica VUL further certify that the Prospectuses were delivered
2001 policy I am applying for, and the underlying Funds. and that no written sales materials other than those
furnished or approved by the Company were used.
I UNDERSTAND THAT ANY DEATH BENEFITS IN EXCESS OF THE FACE AMOUNT AND ANY
POLICY VALUE OF THE FLEXIBLE PREMIUM VARIABLE LIFE INSURANCE POLICY APPLIED ____________________________________________________
FOR, MAY INCREASE OR DECREASE TO REFLECT THE INVESTMENT EXPERIENCE OF THE Signature of Registered Representative Date
SUB-ACCOUNTS OF THE VARIABLE ACCOUNT. THE POLICY VALUE ALLOCATED TO THE ____________________________________________________
FIXED ACCOUNT WILL ACCUMULATE INTEREST AT A RATE SET BY THE COMPANY WHICH Print Name of Registered Representative TR Code/
WILL NOT BE LESS THAN THE MINIMUM GUARANTEED RATE OF 4% ANNUALLY. THERE IS Reg Rep #
NO GUARANTEED MINIMUM POLICY VALUE. THE POLICY VALUE MAY DECREASE TO THE ( )__________________________ ( )______________
POINT WHERE THE POLICY WILL LAPSE AND PROVIDE NO FURTHER DEATH BENEFIT Telephone FAX
WITHOUT ADDITIONAL PREMIUM PAYMENTS. ____________________________________________________
Name of Broker/Dealer Branch #
It is agreed that: (1) The application consists of this application form, ____________________________________________________
the medical questionnaire and the supplemental application to apply for Branch Office Street Address
insurance on family members, if it applies; (2) The representations are ____________________________________________________
true and complete to the best of my knowledge and belief; (3) No City State Zip
FOR HOME OFFICE USE ONLY
____________________________________________________
____________________________________________________
ALLMERICA FINANCIAL 440 Lincoln Street SUPPLEMENT TO ENROLLMENT FORM
LIFE INSURANCE AND ANNUITY Worcester, MA 01653 FOR GROUP FLEXIBLE PREMIUM
COMPANY VARIABLE LIFE INSURANCE
Proposed Insured ___________________________________________________________________
1. ALLOCATION OF NET PREMIUM
The total allocation, in WHOLE PERCENTAGES MUST, TOTAL 100%. Please refer to the Prospectuses for a definition of
"net premium" and for information about the General Account and other sub-accounts of the Variable Account.)
Investment Options Investment Objective
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% Morgan Stanley Dean Witter Technology Portfolio |
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% Allmerica Select Strategic Growth Fund |
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% Allmerica Select Aggressive Growth Fund | Aggressive Growth
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% Allmerica Select Capital Appreciation Fund |
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% Allmerica Select Value Opportunity Fund |
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% Allmerica Select Emerging Markets Fund |
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% Allmerica Select International Equity Fund |
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% Fidelity VIP Overseas Portfolio | International
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% T. Rowe Price International Stock Portfolio |
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% Delaware International Equity Series |
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% Fidelity VIP Growth Portfolio |
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% Allmerica Select Growth Fund | Growth
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% Allmerica Core Equity Fund |
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% Fidelity VIP II Contrafund |
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% Allmerica Select Growth & Income Fund |
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% Fidelity VIP II Index 500 Portfolio | Growth/Income
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% Allmerica Equity Index Fund |
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% Fidelity VIP Equity-Income Portfolio |
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% Fidelity VIP II Asset Manager Portfolio | Asset Allocation
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% Fidelity VIP High Income Portfolio |
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% Allmerica Select Investment Grade Income Fund | Income
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% Allmerica Government Bond Fund |
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% Allmerica Money Market Fund | Capital Preservation
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% General Account |
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%
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%
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%
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%
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100 % Total
I understand that funds may be deposited to a MAXIMUM of twenty sub-accounts. ALL NET PAYMENTS WILL BE ALLOCATED TO THE
ALLMERICA MONEY MARKET FUND UNLESS SPECIFIED OTHERWISE.
(Continued on back. Complete Registered Representative's Report on back of this form for NASD required information)
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2. MONTHLY INSURANCE AND ADMINISTRATIVE CHARGES
Monthly insurance and administrative charges will be deducted pro-rata from all sub-accounts noted on the front of this form
unless otherwise indicated by written request.
I acknowledge receipt of a current prospectus describing the Group Flexible Premium Variable Life Insurance, including the
underlying funds.
I UNDERSTAND THAT THE DEATH BENEFIT AND DURATION OF COVERAGE FOR THE GROUP FLEXIBLE PREMIUM VARIABLE LIFE INSURANCE APPLIED FOR
MAY INCREASE OR DECREASE TO REFLECT THE INVESTMENT EXPERIENCE OF THE SUB-ACCOUNTS OF THE ALLMERICA FINACIAL LIFE INSURANCE AND
ANNUITY COMPANY VARIABLE ACCOUNT.
I UNDERSTAND THAT THE CERTIFICATE VALUE FOR THE GROUP FLEXIBLE PREMIUM VARIABLE LIFE INSURANCE CERTIFICATE APPLIED FOR MAY
INCREASE OR DECREASE TO REFLECT THE INVESTMENT EXPERIENCE OF THE SUB-ACCOUNTS OF THE ALLMERICA FINANCIAL LIFE INSURANCE AND
ANNUITY COMPANY VARIABLE ACCOUNT, AND IS NOT GUARANTEED AS TO DOLLAR AMOUNT. THERE IS NO GUARANTEED MINIMUM CERTIFICATE VALUE.
I believe that Group Flexible Premium Variable Life Insurance is consistent with my investment objectives and financial needs.
Signature of Owner and Capacity
__________________________________________________________________________________________________________________________________
Signed at (City and State) Date
_________________________________________________________________ ____________________________________________________________
3. SPECIAL REQUESTS
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
REGISTERED REPRESENTATIVE'S REPORT
1. The Owner [ ] is [ ] is not an associated person of another broker/dealer.
2. Based on information furnished by the Owner, I believe that a Group Flexible Premium Variable Life Insurance certificate is
consistent with the Owner's investment objectives for (state objectives):
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
3. The Owner's tax status is (indicate tax bracket and any other pertinent tax information):
_____________________________________________________________________________________________________________________________
4. I certify that reasonable effort was made to obtain and record information pertaining to the suitability of this application.
5. I further certify that the Prospectuses were delivered, and that no written sales materials were used other than those
furnished or approved by the Principal Office.
Signature Underwriting Approval
________________________________________________________ ___________________________________________________________________
Registered Representative (Completed in Principal Office)
[LOGO] ALLMERICA ALLMERICA FINANCIAL
FINANCIAL-Registered Trademark- LIFE INSURANCE AND 440 Lincoln Street INFORMATION ABOUT THE
ANNUITY COMPANY Worcester, MA 01653 INSURED
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Have you ever had any of the following conditions:
Yes No
Kidney Disorder / / / /
Heart Disease or Stroke / / / /
Cancer / / / /
Diabetes / / / /
In the past 10 years, has a member of the medical profession diagnosed or treated you for immune system disorder, including
acquired immune deficiency syndrome (AIDS) or AIDS-related complex (ARC)?
Yes / / No / /
Have you HAD an illness or injury during the last six months that has prevented you from working five consecutive days?
Yes / / No / / If yes, please explain:
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
Please provide the name of the last physician consulted, date and reason for consultation:
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
During the last three years, have you had a motor vehicle license suspended or revoked or was convicted of either driving while
intoxicated or of more than one moving violation?
Yes/ / No/ / If yes, please explain:
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
During the past three years, have you participated in or intend to participate in:
/ / Scuba diving / / Skydiving / / Motor racing
/ / Hang gliding or similar flying activity
During the past three years, have you flown or intend to fly as a trainee, pilot or crew member?
Yes / / No / /
Will you be traveling outside of the United States or Canada in the next six months?
Yes / / No / / If yes, please indicate country:
__________________________________________________________________________________________________________________________________