EXHIBIT 1(10)
APPLICATION
[ALLMERICA SELECT LOGO]
ALLMERICA FINANCIAL
LIFE INSURANCE AND 440 Lincoln Street
ANNUITY COMPANY Worcester, MA 01653 [SPL APPLICATION]
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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 [14] of the [14] variable
accounts listed below and the Fixed Account.]
YOUR TOTAL ALLOCATION MUST EQUAL 100%
________ % Select Emerging Markets
________ % Select International Equity
________ % T. Rowe Price International Stock
________ % Select Aggressive Growth
________ % Select Capital appreciation
________ % Select Value Opportunity
________ % Select Growth
________ % Select Strategic Growth
________ % Fidelity VIP Growth Portfolio
________ % Select Growth and Income
________ % Fidelity VIP Equity Income Portfolio
________ % Fidelity VIP High Income Portfolio
________ % Select Income
________ % 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.)
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 Income* or / / Money Market*
(*This account cannot be selected in the allocation below.)]
EVERY: / / Month / / Quarter / / 6 Mos. / / 12 Mos.
INTO: ________ % Select Emerging Markets
________ % Select International Equity
________ % T. Rowe Price International Stock
________ % Select Aggressive Growth
________ % Select Capital Appreciation
________ % Select Value Opportunity
________ % Select Growth
________ % Select Strategic Growth
________ % Fidelity VIP Growth Portfolio
________ % Select Growth and Income
________ % Fidelity VIP Equity Income Portfolio
________ % Fidelity VIP High Income Portfolio
________ % Select Income
________ % Allmerica Money Market
________ %
________ %
________ %
________ %
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
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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
AS-401 Page 1 (12/97)
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)
10 INFORMATION ABOUT THE INSURED
10a CURRENT EMPLOYMENT.
Employer's Name:
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Occupation and Responsibilities:
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10b INCOME
My annual earned income is $
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My annual unearned income is $
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My net worth is $
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10c DURING THE PAST YEAR, I HAVE SMOKED ONE OR MORE CIGARETTES, CIGARS,
PIPES, OR USED CHEWING TOBACCO.
/ / Yes / / No
10c Height Weight
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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
( ) / /
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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
Page 2
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.
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] 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
Page 3
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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TR Code (Indicate A, B, or C)
( ) ( )
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Telephone Fax
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Name of Broker/Dealer Branch #
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Branch Office Street Address
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City State Zip
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FOR HOME OFFICE USE ONLY
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Page 4
[ALLMERICA SELECT LOGO]
ALLMERICA FINANCIAL
LIFE INSURANCE AND 440 Lincoln Street INFORMATION ON SECOND INSURED
ANNUITY COMPANY Worcester, MA 01653 [SPL APPLICATION]
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1 SECOND INSURED
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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 ---------------
Date of Birth Sex State of Birth
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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:
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Occupation and Responsibilities:
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4b INCOME
My annual earned income is $
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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
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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:
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I AM CURRENTLY BEING TREATED: / / YES / / NO
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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
Page 1
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
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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
Page 2