<Page>
[ALLMERICA FINANCIAL LOGO]
ALLMERICA FINANCIAL
LIFE INSURANCE AND 440 Lincoln Street
ANNUITY COMPANY Worcester, MA 01653 ALLMERICA SPL II
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1 PAYMENT The monetary contribution to the policy.
CHECK ONE:
/ / I have enclosed a check for my initial payment of $____________
and have received a conditional receipt.
(Please make check payable to Allmerica Financial)
/ / My initial payment will be transferred from another insurance
company. Approximate amount $____________. The amount of insurance
purchased will be the minimum allowed by the IRS Guideline Single
Premium unless you designate a higher amount $_________________________.
(Please attach Transfer of Assets form)
2 ALLOCATION How I want my payment allocated.
ALLOCATE MY PAYMENT AS FOLLOWS: Please use whole percentages.
You may allocate your payment to no more than 20 of the variable
accounts listed below and the Fixed Account.
YOUR TOTAL ALLOCATION MUST EQUAL 100%
EMERGING MARKETS EQUITY
_____ % Select Emerging Markets
INTERNATIONAL EQUITY
_____ % FT VIP Templeton Foreign Securities
_____ % Oppenheimer Global Securities
_____ % Select International Equity
SMALL CAP EQUITY
_____ % AIM V.I. Aggressive Growth
_____ % AllianceBernstein Small Cap Value
_____ % Fidelity VIP Value Strategies
_____ % FT VIP Small Cap
_____ % FT VIP Small Cap Value Securities
_____ % MFS New Discovery
_____ % Select Strategic Growth
_____ % Mid Cap Equity
_____ % AIM V.I. Capital Development
_____ % Fidelity VIP III Mid Cap
_____ % FT VIP Mutual Shares Securities
_____ % MFS Mid Cap Growth
_____ % Select Capital Appreciation
_____ % Select Value Opportunity
LARGE CAP GROWTH EQUITY
_____ % AIM V.I. Blue Chip
_____ % AIM V.I. Premier Equity
_____ % Alliance Premier Growth
_____ % Alliance Technology
_____ % Allmerica Core Equity
_____ % Allmerica Equity Index
_____ % Fidelity VIP Growth
_____ % FT VIP Franklin Large Cap Growth
_____ % Oppenheimer Capital Appreciation
_____ % Select Aggresssive Growth
_____ % Select Growth
LARGE CAP VALUE EQUITY
_____ % AIM V.I. Basic Value
_____ % AllianceBernstein Value
_____ % Alliance Growth & Income
_____ % Fidelity VIP Contrafund
_____ % Fidelity Equity Income
_____ % MFS Total Return
_____ % MFS Utilities
_____ % Oppenheimer Main Street Growth & Income
_____ % Oppenheimer Multiple Strategies
_____ % Select Growth & Income
HIGH YIELD BOND
_____ % Oppenheimer High Income
_____ % Fixed Income
_____ % Allmerica Government Securities
_____ % Select Investment Grade Income
_____ % Select Strategic Income
CASH AND EQUIVALENTS
_____ % Allmerica Money Market
_____ % Fixed Account
100 % TOTAL
Any future payment will be allocated according to this selection
unless changed by me.
3 ACCOUNT REBALANCING
/ / I elect Automatic Account Rebalancing of the variable
accounts to the allocations specified in Section 2, above.
/ / Monthly / / Quarterly / / Semi-Annually / / Annually
(Automatic Account Rebalancing and Dollar Cost Averaging cannot be in
effect simultaneously.)
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4 DOLLAR COST AVERAGING
Select ONE account from which to transfer money. Be sure you have
money allocated to this account in Section 2.
Transfer $____________ ($100 Minimum)
FROM: / / Fixed Account or
/ / Select Investment Grade Income* or / / Money Market*
(*This account cannot be selected in the allocation below.)
EVERY: / / Month / / Quarter / / 6 Mos. / / 12 Mos.
INTO:
EMERGING MARKETS EQUITY
_____% Select Emerging Markets
INTERNATIONAL EQUITY
_____% FT VIP Templeton Foreign Securities
_____% Oppenheimer Global Securities
_____% Select International Equity
SMALL CAP EQUITY
_____% AIM V.I. Aggressive Growth
_____% AllianceBernstein Small Cap Value
_____% Fidelity VIP Value Strategies
_____% FT VIP Small Cap
_____% FT VIP Small Cap Value Securities
_____% MFS New Discovery
_____% Select Strategic Growth
_____% Mid Cap Equity
_____% AIM V.I. Capital Development
_____% Fidelity VIP III Mid Cap
_____% FT VIP Mutual Shares Securities
_____% MFS Mid Cap Growth
_____% Select Capital Appreciation
_____% Select Value Opportunity
LARGE CAP GROWTH EQUITY
_____% AIM V.I. Blue Chip
_____% AIM V.I. Premier Equity
_____% Alliance Premier Growth
_____% Alliance Technology
_____% Allmerica Core Equity
_____% Allmerica Equity Index
_____% Fidelity VIP Growth
_____% FT VIP Franklin Large Cap Growth
_____% Oppenheimer Capital Appreciation
_____% Select Aggresssive Growth
_____% Select Growth
LARGE CAP VALUE EQUITY
_____% AIM V.I. Basic Value
_____% AllianceBernstein Value
_____% Alliance Growth & Income
_____% Fidelity VIP Contrafund
_____% Fidelity Equity Income
_____% MFS Total Return
_____% MFS Utilities
_____% Oppenheimer Main Street Growth & Income
_____% Oppenheimer Multiple Strategies
_____% Select Growth & Income
HIGH YIELD BOND
_____% Oppenheimer High Income
_____% Fixed Income
_____% Allmerica Government Securities
_____% Select Investment Grade Income
_____% Select Strategic Income
CASH AND EQUIVALENTS
_____% Allmerica Money Market
_____% Fixed Account
100 % TOTAL
5 INSURED The person upon whose life this insurance coverage is proposed.
For second insured, complete Form AS-426.
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First Name Middle Last
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Street Address
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City State Zip
( )
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Daytime Telephone Number Years at this Address
/ / / / M / / F
- ------------------- Sex ---------------
Date of Birth State of Birth
- ------------------------------------- --------------------------
Social Security/Tax I.D. Number Driver's License Number
6 OWNER The person or entity exercising the policy's contractual rights.
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First Name Middle Last
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Street Address
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City State Zip
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Social Security/Tax I.D. Number Date of Trust
7 BENEFICIARY
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Name of Primary Beneficiary Relationship to Insured
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Name of Contingent Beneficiary Relationship to Insured
8 REPLACEMENT OF OTHER CONTRACTS
WILL THE PROPOSED POLICY REPLACE ANY EXISTING ANNUITY OR LIFE INSURANCE POLICY?
/ / Yes / / No
If yes, list company name and policy number:
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9 TELEPHONE ACCESS
I WILL AUTOMATICALLY BE ABLE TO TRANSFER ACCOUNT VALUES AND CHANGE THE
ALLOCATION OF FUTURE INVESTMENTS BY TELEPHONE OR FAX UNLESS I CHECK THE BOX
BELOW.
/ / I DO NOT accept the Telephone Access privilege.
(Please see additional information in the Authorization and Signature Section)
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10 INFORMATION ABOUT THE INSURED
10a CURRENT EMPLOYMENT.
Employer's Name:
-------------------------------------------------------
Occupation and Responsibilities:
---------------------------------------
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10b INCOME
My annual earned income is $
--------------
My annual unearned income is $
--------------
My net worth is $
--------------
10c DURING THE PAST YEAR, I HAVE SMOKED ONE OR MORE CIGARETTES, CIGARS,
PIPES, OR USED CHEWING TOBACCO.
/ / Yes / / No
10d Height Weight
---------------- ----------------
11 MEDICAL HISTORY
11a DURING THE PAST 10 YEARS, I HAVE HAD, OR BEEN TREATED FOR HEART, LIVER,
LUNG, OR KIDNEY TROUBLE, HIGH BLOOD PRESSURE, STROKE, DIABETES, CANCER,
NERVOUS OR PSYCHOLOGICAL DISORDERS, OR ALCOHOL OR DRUG ABUSE.
/ / Yes / / No
11b DURING THE PAST 10 YEARS, I HAVE HAD, OR BEEN TREATED FOR IMMUNE
SYSTEM DISORDER INCLUDING ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS),
AIDS-RELATED COMPLEX, OR ANOTHER IMMUNE DISORDER.
/ / Yes / / No
IF YOU ANSWERED "YES" TO 11a OR 11b, PLEASE COMPLETE ITEMS 11c THROUGH 11f:
11c I HAVE BEEN DIAGNOSED OR TREATED FOR:
-----------------------------------
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I AM CURRENTLY BEING TREATED: / / YES / / NO
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Primary Physician's Name
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Health Care Provider
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Street Address
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City State Zip
( ) / /
------------------------------------ ------------------------------------
Telephone Date of Last Visit
11d DURING THE PAST THREE YEARS, I HAVE PARTICIPATED IN, OR INTEND TO
PARTICIPATE IN:
/ / Scuba Diving / / Skydiving / / Land/Water Racing
/ / Hang Gliding or similar flying activity
11e DURING THE PAST TWO YEARS, I HAVE FLOWN, OR INTEND TO FLY, AS A
TRAINEE, PILOT, OR CREW MEMBER.
/ / Yes / / No
11f DURING THE PAST THREE YEARS, I HAVE HAD A MOTOR VEHICLE LICENSE
SUSPENDED OR REVOKED, OR BEEN CONVICTED OF DRIVING WHILE INTOXICATED OR
OF MORE THAN ONE MOVING VIOLATION.
/ / Yes / / No
AUTHORIZATIONS AND SIGNATURES
AUTHORIZATION TO OBTAIN INFORMATION
To all physicians, medical professionals, hospitals, clinics, other health
care providers, employers, Medical Information Bureau, Inc. (MIB), consumer
reporting agencies, other insurance support organizations, the United
States Internal Revenue Service, the Puerto Rico Bureau of Income Tax, and
other persons who have the types of information described about the
proposed Insured:
I authorize you to give the Company, its reinsurers, or its agent (a) all
information you have as to illness, injury, medical history, diagnosis,
treatment, and prognosis (including any drug or alcohol abuse condition or
treatment) with respect to any physical or mental condition of the proposed
Insured; and (b) any non-medical information, including but not limited to,
an investigative consumer report and copies of my tax returns filed with
the United States Internal Revenue Service and/or Puerto Rico Bureau of
Income Tax, which the Company believes it needs to perform the business
functions described below. I also authorize the Company to give the MIB
health or non-medical information it has about me and that of any minor
member of my family applying for insurance.
The information obtained will be used to determine if the proposed Insured
is eligible for: (a) the insurance requested; or (b) benefits under a
policy which is in force. It will also be used for any other business
purpose which relates to the insurance requested or the policy which is in
force. This authorization will be valid for 30 months. I know that under
Federal Regulations I may revoke this authorization as it applies to drug
and alcohol abuse treatment at any time, but my revocation will not effect
any information that has been released prior thereto. I know that I may
request a copy of this form. I agree that a photocopy is as valid as the
original. I have received the Insurance Information Practices notice.
I understand that Allmerica Financial Life Insurance and Annuity Company is
authorized to honor telephone requests by me or by individuals authorized
by me, to transfer account values among sub-accounts and to change the
allocation of my future payments. I also understand that withdrawal of
funds from my policy cannot be transacted by telephone or fax instructions.
3
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VARIABLE PRODUCT DISCLOSURE
I UNDERSTAND THAT ANY DEATH BENEFITS IN EXCESS OF THE FACE AMOUNT AND ANY
POLICY VALUE OF THE POLICY APPLIED FOR, MAY INCREASE OR DECREASE TO REFLECT
THE INVESTMENT EXPERIENCE OF THE 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 WILL NOT BE LESS THAN THE MINIMUM GUARANTEED
RATE OF 4% ANNUALLY. THERE IS NO GUARANTEED MINIMUM POLICY VALUE. THE
POLICY VALUE MAY DECREASE TO THE POINT WHERE THE POLICY WILL LAPSE AND
PROVIDE NO FURTHER DEATH BENEFIT WITHOUT ADDITIONAL PAYMENTS.
ACKNOWLEDGEMENTS AND AGREEMENTS
I acknowledge receipt of current Prospectuses describing the
Allmerica Select SPL II policy that I am applying for, and the underlying
funds.
It is agreed that: (1) The application consists of this application form,
the medical questionnaire, if any, and the information on the Second
Insured form, if it applies; (2) The representations are true and complete
to the best of my knowledge and belief; (3) No liability exists and the
insurance applied for will not take effect until the policy is delivered
and the payment is made during the lifetime of the proposed Insured(s) and
then only if the proposed Insured(s) has (have) not consulted any physician
or practitioner of any healing art nor had any tests listed in the
application since its completion; but if the payment is paid prior to
delivery of the policy and a conditional receipt is delivered by the
registered representative, insurance will be effective subject to the terms
of the conditional receipt; and (4) No registered representative or broker
is authorized to amend, alter, or modify the terms of this agreement.
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Signature of Insured Date
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Print Name of Insured
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Signed at City State
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Signature of Owner (if other than Insured) Date
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Print Name of Owner
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Signed at City State
FOR FINANCIAL REPRESENTATIVE USE ONLY
Does the policy applied for replace an existing annuity or life insurance
policy?
/ / Yes / / No
If yes, attach replacement forms as required.
As Registered Representative, I certify witnessing the signature of the
applicant and that the information in this application has been accurately
recorded to the best of my knowledge and belief.
Based on the information furnished by the Owner or Insured in this
application, I certify that I have reasonable grounds for believing the
purchase of the policy applied for is suitable for the Owner. I further
certify that the Prospectuses were delivered and that no written sales
materials other than those furnished by the Company were used.
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Signature of Registered Representative Date
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Print Name of Registered Representative Reg Rep #
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Signature of Registered Representative Date
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Print Name of Registered Representative Reg Rep #
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TR Code
( ) ( )
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Telephone Fax
-----------------------------------------------------------------------------
Name of Broker/Dealer Branch #
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Branch Office Street Address
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City State Zip
REMARKS: ---------------------------------------------------------------------
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FOR HOME OFFICE USE ONLY
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4
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[ALLMERICA FINANCIAL LOGO]
ALLMERICA FINANCIAL
LIFE INSURANCE AND 440 Lincoln Street INFORMATION ON SECOND
ANNUITY COMPANY Worcester, MA 01653 INSURED ALLMERICA SPL II
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1 SECOND INSURED
- -------------------------------------------------------------------------------
First Name Middle Last
- -------------------------------------------------------------------------------
Street Address
- -------------------------------------------------------------------------------
City State Zip
( )
- -------------------------------------------------------------------------------
Daytime Telephone Number Years at this Address
/ /
- ------------------ / / M / / F ---------------
Date of Birth Sex State of Birth
- -------------------------------------------------------------------------------
Social Security/Tax I.D. Number Driver's License Number
2 OWNER AND BENEFICIARY
The Owner and Beneficiary are as indicated in Section 6 and 7 of the
accompanying SPL application. If Section 6 is left blank, the Owner will
be the insured listed in Section 5 of the SPL application.
3 REPLACEMENT OF OTHER CONTRACTS
WILL THE PROPOSED POLICY REPLACE ANY EXISTING ANNUITY OR LIFE INSURANCE
POLICY?
/ / Yes / / No
If yes, list company name and policy number:
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4 INFORMATION ABOUT THE INSURED
4a CURRENT EMPLOYMENT.
Employer's Name:
--------------------------------------------------------
Occupation and Responsibilities:
----------------------------------------
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4b INCOME
My annual earned income is $
--------------
My annual unearned income is $
--------------
My net worth is $
--------------
4c DURING THE PAST YEAR, I HAVE SMOKED ONE OR MORE CIGARETTES, CIGARS,
PIPES, OR USED CHEWING TOBACCO.
/ / Yes / / No
4d Height Weight
---------------- ----------------
5 MEDICAL HISTORY
5a DURING THE PAST 10 YEARS, I HAVE HAD, OR BEEN TREATED FOR HEART, LIVER,
LUNG, OR KIDNEY TROUBLE, HIGH BLOOD PRESSURE, STROKE, DIABETES, CANCER,
NERVOUS OR PSYCHOLOGICAL DISORDERS, OR ALCOHOL OR DRUG ABUSE.
/ / Yes / / No
5b DURING THE PAST 10 YEARS, I HAVE HAD, OR BEEN TREATED FOR IMMUNE
SYSTEM DISORDER INCLUDING ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS),
AIDS-RELATED COMPLEX, OR ANOTHER IMMUNE DISORDER.
/ / Yes / / No
IF YOU ANSWERED "YES" TO 5a OR 5b, PLEASE COMPLETE ITEMS 5C THROUGH 5F:
5c I HAVE BEEN DIAGNOSED OR TREATED FOR:
------------------------------------
-------------------------------------------------------------------------
-------------------------------------------------------------------------
-------------------------------------------------------------------------
I AM CURRENTLY BEING TREATED: / / YES / / NO
-------------------------------------------------------------------------
Primary Physician's Name
-------------------------------------------------------------------------
Health Care Provider
-------------------------------------------------------------------------
Street Address
-------------------------------------------------------------------------
City State Zip
( ) / /
------------------------------------- --------------------------------
Telephone Date of Last Visit
5d DURING THE PAST THREE YEARS, I HAVE PARTICIPATED IN, OR INTEND TO
PARTICIPATE IN:
/ / Scuba Diving / / Skydiving / / Land/Water Racing
/ / Hang Gliding or similar flying activity
5e DURING THE PAST TWO YEARS, I HAVE FLOWN, OR INTEND TO FLY, AS A
TRAINEE, PILOT, OR CREW MEMBER.
/ / Yes / / No
5f DURING THE PAST THREE YEARS, I HAVE HAD A MOTOR VEHICLE LICENSE
SUSPENDED OR REVOKED, OR BEEN CONVICTED OF DRIVING WHILE INTOXICATED OR
OF MORE THAN ONE MOVING VIOLATION.
/ / YES / / No
5
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AUTHORIZATIONS AND SIGNATURES
AUTHORIZATION TO OBTAIN INFORMATION
To all physicians, medical professionals, hospitals, clinics, other health
care providers, employers, Medical Information Bureau, Inc. (MIB), consumer
reporting agencies, other insurance support organizations, the United
States Internal Revenue Service, the Puerto Rico Bureau of Income Tax, and
other persons who have the types of information described about the
proposed Insured:
I authorize you to give the Company, its reinsurers, or its agent (a) all
information you have as to illness, injury, medical history, diagnosis,
treatment, and prognosis (including any drug or alcohol abuse condition or
treatment) with respect to any physical or mental condition of the proposed
Insured; and (b) any non-medical information, including but not limited to,
an investigative consumer report and copies of my tax returns filed with
the United States Internal Revenue Service and/or Puerto Rico Bureau of
Income Tax, which the Company believes it needs to perform the business
functions described below. I also authorize the Company to give the MIB
health or non-medical information it has about me and that of any minor
member of my family applying for insurance.
The information obtained will be used to determine if the proposed Insured
is eligible for: (a) the insurance requested; or (b) benefits under a
policy which is in force. It will also be used for any other business
purpose which relates to the insurance requested or the policy which is in
force. This authorization will be valid for 30 months. I know that under
Federal Regulations I may revoke this authorization as it applies to drug
and alcohol abuse treatment at any time, but my revocation will not effect
any information that has been released prior thereto. I know that I may
request a copy of this form. I agree that a photocopy is as valid as the
original. I have received the Insurance Information Practices notice.
ACKNOWLEDGEMENTS AND AGREEMENTS
It is agreed that: (1) The application consists of this application form,
the medical questionnaire, if any, and the information on the Second
Insured form; (2) The representations are true and complete to the best of
my knowledge and belief; (3) No liability exists and the insurance applied
for will not take effect until the policy is delivered and the payment is
made during the lifetime of the proposed Insured(s) and then only if the
proposed Insured(s) has (have) not consulted any physician or practitioner
of any healing art nor had any tests listed in the application since its
completion; but if the payment is paid prior to delivery of the policy and
a conditional receipt is delivered by the registered representative,
insurance will be effective subject to the terms of the conditional
receipt; and (4) No registered representative or broker is authorized to
amend, alter, or modify the terms of this agreement.
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Signature of Second Insured Date
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Print Name of Second Insured
-----------------------------------------------------------------------------
Signed at City State
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Signature of Owner (if other than Insured) Date
-----------------------------------------------------------------------------
Print Name of Owner
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Signed at City State
6
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[ALLMERICA FINANCIAL LOGO]
Regular Mail: Overnight Mail:
PO Box 8179 66 Brooks Drive ALLMERICA SPL II
Boston, MA 02266-8179 Braintree, MA 02184 TRANSFER OF ASSETS 1035 EXCHANGE
- --------------------------------------------------------------------------------
<Table>
ALLMERICA FINANCIAL LIFE INSURANCE AND ANNUITY COMPANY FIRST ALLMERICA FINANCIAL LIFE INSURANCE COMPANY
1. INFORMATION FROM CONTRACT/POLICY/ACCOUNT(S) TO BE TRANSFERRED:
Owner _____________________________________________________________________________SSN __________________________________________
Joint Owner _______________________________________________________________________SSN __________________________________________
Annuitant/Insured _________________________________________________________________SSN __________________________________________
Assets From: Company ___________________________________________________________________________________________________________
Department _______________________________Contact Name (if available)______________________________________________
PLEASE INCLUDE Company Address ___________________________________________________________________________________________________
COMPLETE
STREET ADDRESS. City __________________________________________________State ______________________Zip Code________________________
Telephone (_________________)____________________________
Contract/Policy/Account(s) # ____________________ # ______________________#__________________
2. This is a / / total (100%) liquidation of assets; transfer in cash
or / / Partial withdrawal of $_______________ from: / / Annuities / / Life Insurance / / Bank
/ / Brokerage - copy of most recent statement required / / Mutual funds - copy of most recent statement required
To be effected / / IMMEDIATELY / / AT MATURITY DATE_______________________ / / OTHER DATE__________________.
3. If this transfer is of LIFE or ANNUITY Contracts, the Contract #(s) ___________________________________________________________
is/are / / Enclosed / / Misplaced / / Destroyed
4. TYPE OF TRANSFER-CHECK ONE ONLY Additional Comments:
/ / Qualified (complete Sections 6, 7 and 8)
/ / Non-Qualified 1035 Exchange (complete Section 7 and 9 on reverse side)
/ / Other Non-Qualified (complete Section 7)
5. My present contract has a loan that I wish to carry over to the new contract. / / YES / / NO
Loan carry over amount $________________
Total approximate transfer amount $________________ (transfer payment and loan carry over)
6. QUALIFIED TRANSFER FROM-CHECK ONE ONLY NOTE: AGE 70 1/2 RESTRICTIONS APPLY TO A
/ / IRA / / Roth IRA Contributory RETIREMENT ACCOUNT TRANSFER: If you are age
/ / Roth IRA Conversion - Year:_______ Value:_________ 70 1/2 or older this year, you may not
/ / 401(k) / / 401(a) (Trustee/Custodian Transfer) / / Rollover of Distribution transfer or rollover required minimum
/ / 403(b) - TSA Direct (Revenue Ruling 90-24) Transfer distribution amounts. If necessary, instruct
your present trustee/custodian, prior to
effecting this transfer to either: 1) pay
your own required minimum distribution to
you now; or (2) retain that amount for
distribution to you later. Not applicable to
Roth IRA.
7. / / YES / / NO APPLY 60-DAY GUARANTEE PERIOD ACCOUNT RATE LOCK.
NOTE: RATE LOCK IS IRREVOCABLE and is available for 1035 exchanges and transfers of assets from trustee
to trustee. The current rate will be locked in for 60 days from receipt of completed instructions/forms
at the Company, after which time it will revert to the rate then in effect. Guarantee Period Accounts are
not available in all contracts/states.
8. I request that the above referenced contract/policy/account(s) be transferred to the above referenced
Company. Please do not withhold taxes. I AM AWARE OF ANY PENALTIES OR SURRENDER CHARGES THAT WILL RESULT
FROM THIS LIQUIDATION BY THE PREVIOUS COMPANY. I AM FURTHER AWARE THAT ANY TAX CONSEQUENCES OF THIS
TRANSACTION ARE SOLELY MY OWN AND THAT I MAY WISH TO CONSULT MY TAX ADVISOR.
Date __________________________________________ Signature_____________________________________________________
Contract Owner
Date __________________________________________ Signature_____________________________________________________
Contract Joint Owner
SIGNATURE GUARANTEE: (required for MUTUAL FUNDS, BROKERAGE ACCOUNTS, or as requested)
Allmerica Financial Life Insurance/First Allmerica Financial Life Insurance Contract/Policy Number___________________________
SEE REVERSE FOR NON-QUALIFIED/1035 EXCHANGE INFORMATION
</Table>
7
<Page>
9. NON-QUALIFIED 1035 EXCHANGE (MUST BE COMPLETED FOR TRANSFER OF LIFE AND
ANNUITY CONTRACTS UNDER 1035 REGULATIONS.)
I hereby absolutely assign and transfer the above identified life
policies/annuity contract(s) to First Allmerica Financial Life Insurance Company
or Allmerica Financial Life Insurance and Annuity Company (herein called the
Company), its successors and assigns, along with any and all claims, options,
privileges, rights, title and interest therein, and subject to all conditions of
such policy(ies)/contract(s). All previous designations of beneficiary are
revoked. The undersigned declares that the sole beneficiary shall be the
Company, its successors or assigns. I further declare that no proceedings in
bankruptcy are pending against the undersigned and that the
policy(ies)/contract(s) is/are not subject to any other assignment, pledge or
lien.
The undersigned intends this assignment to be part of an exchange of insurance
policies or annuity contracts under Internal Revenue Code Section 1035. The
Company agrees in consideration for this assignment either to issue a new policy
or contract in exchange for the policy or contract assigned, or if the policy is
being exchanged for a new policy of life insurance, to reassign the policy or
contract to the undersigned if the application for the new policy is not
approved by the Company on either a standard or non-standard basis. Amounts
credited to the new policy or contract will be the amount actually received from
the original carrier and will be credited on the day it is received in the
Company's Home/Principal Office.
If the life policy being exchanged is non-qualified and a policy loan is
outstanding or part of the cash surrender value is refunded to me, I understand
that the proposed transaction may result in a taxable gain. If the life policy
being exchanged is qualified and a policy loan is outstanding or part of the
cash surrender value is refunded to the plan trustee, I understand that all or
part of the PS-58 cost basis in the existing policy may be lost.
All powers, elections, appointments, options and rights exercisable by me as
owner (including the right to surrender) are now exercisable by the Company,
subject to acceptance by the issuing company, which shall relate back to the
date of my signature.
Date_________________ Owner-
Assignor _____________________________________
Joint-Owner
Assignor _____________________________________
Irrevocable
Beneficiary____________________________________
NOTIFICATION OF ACCEPTANCE/SURRENDER
The Company will accept the transfer described. Please liquidate the account or
surrender the policy or contract without withholding taxes. Please provide the
following information with your check and mail to:
Allmerica Select
Allmerica Financial
PO Box 8179
Boston, MA 02266-8179
(800) 366-1492
<Table>
Contract/Policy # ___________FBO ___________ First Allmerica Financial Life Insurance Company
Allmerica Financial Life Insurance and Annuity Company
Type _______________________________________
Date ______________________________________ _______________________________________________
Signature/Title
</Table>
8
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[ALLMERICA FINANCIAL LOGO]
ALLMERICA FINANCIAL
LIFE INSURANCE AND 440 Lincoln Street
ANNUITY COMPANY Worcester, MA 01653 INSURANCE INFORMATION PRACTICES
- --------------------------------------------------------------------------------
Personal information about you may be obtained from persons other than you. You
have a right of access and correction with respect to personal information
obtained about you. The Company may in some cases also disclose personal or
privileged information it has about you to other third parties without your
authorization. A detailed description of the Company's information practices
will be furnished on your request.
Any request for information should be directed to Allmerica Financial Services,
Individual Underwriting, 440 Lincoln Street, Worcester, MA 01653.
MEDICAL INFORMATION BUREAU PRE-NOTICE
Information regarding your insurability and/or any past or future claims will be
treated as confidential. The Company, or its reinsurers, may, however, make a
brief report thereon to the Medical Information Bureau, a non-profit membership
organization of life insurance companies which operates an information exchange
on behalf of its members. If you apply to another Bureau member company for life
or health insurance coverage, or a claim for benefits is submitted to such a
company, the Bureau, upon request, will supply such company with the information
in its file.
Upon receipt of your request, the Medical Information Bureau will arrange for
disclosure of the information about you contained in its file. If you question
the accuracy of the information in the Bureau's file, you may contact the Bureau
to seek a correction in accordance with the procedure established in the Federal
Fair Credit Reporting Act. The address of the Bureau's Information office is
P.O. Box 105, Essex Station, Boston, Massachusetts 02112; the Bureau's telephone
number is (617) 426-3660.
The Company, or its reinsurers, may also release information in its file to
other life insurance companies to whom you may apply for life or health
insurance, or to whom a claim for benefits may be submitted.
FAIR CREDIT REPORTING ACT PRE-NOTICE
In making this application for insurance it is understood that an investigative
consumer report may be made. Information will be obtained through personal
interviews with third parties such as family members, business associates,
financial sources, friends, neighbors or others with whom you are acquainted.
This inquiry includes information as to your character, general reputation,
personal characteristics and mode of living, whichever may be applicable. Upon
written request, you will be told if an investigative consumer report has been
ordered. If so, you may ask to be interviewed in connection with its
preparation. You have a right to make a written request within a reasonable
period of time for a complete and accurate disclosure of additional information
concerning the nature and scope of the investigative consumer report. You also
have the right to inspect and obtain a copy of the investigative consumer report
from the investigative consumer reporting agency.
PERSONAL INFORMATION TELEPHONE INTERVIEW
While an underwriter is evaluating your application, we may ask one of our Home
Office Interviewers to contact you for additional information. Whenever
possible, calls will be made at your convenience and to the telephone number you
have provided. Your representative will review with you the information we need
to initiate the call and will record it on a separate form.
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