[VUL 2000 ] ALLMERICA FINANCIAL LIFE
INSURANCE AND ANNUITY COMPANY VARIABLE LIFE APPLICATION
IF [SECOND TO DIE] PLEASE COMPLETE SUPPLEMENTAL APPLICATION.
1 INSURED The person upon whose life this insurance coverage is proposed.
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First Name Middle Last
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Street Address Years at this Address
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City State Zip
( )
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Daytime Telephone Number
M/ D/ Y/
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Date of Birth State of Birth
- - M / / F / /
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Social Security Number Sex
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Driver's License Number State
2 PAYMENT The monetary contribution to the policy.
CHECK ONE:
[ / /I have enclosed a check for my initial payment of $____________________
[($100 minimum)] and have received a conditional receipt.
(Please make check payable to Allmerica Financial Life
Insurance and Annuity Company)]
[ / /My initial payment will be transferred from another insurance
company. Approximate amount $__________________________________________
Name of transferring company___________________________________________
My Transfer of Assets form is attached. Yes / /
My present contract has a loan that I wish to carry over to the
new contract / / Yes / / No
Loan carry over amount $__________________.]
[ 2a I WANT TO MAKE FUTURE PAYMENTS OF $_____________________:
/ / Annually / / Semi-Annually / / Quarterly / / Monthly
(I have included a voided check and Bank Drafting Form.)
/ / Non-bill
/ / List bill specify frequency]
2b PAYMENT REMINDER NOTICES WILL BE SENT TO THE POLICYOWNER
UNLESS SPECIFIED OTHERWISE HERE:
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Name
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Street Address
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City State Zip
3 POLICYOWNER The person or entity exercising the policy's contractual rights.
THE POLICYOWNER WILL BE THE INSURED UNLESS SPECIFIED HERE:
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Name
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Street Address
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City State Zip
Social Security or Tax I.D. Number
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Trust Date M/_______ D/_______ Y/_______ (if Trust owned)
4 ALLOCATION How I want my payments allocated.
Complete Section 4a. Future payments will be allocated according
to this selection unless changed by me.
4a / / ALLOCATE MY PAYMENT AS FOLLOWS: Use whole percentages.
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 Growth Portfolio
_______% Select Growth and Income
_______% Fidelity Equity Income Portfolio
_______% Fidelity High Income Portfolio
_______% Investment Grade Income
_______% Allmerica Money Market
_______% Fixed Account
_______%
100 % TOTAL ]
Deductions of all charges will be made pro rata according to
the value of each account and the Fixed Account unless other-
wise specified in the "Remarks" section of the application.
4b AUTOMATIC ACCOUNT REBALANCING
/ / I elect Automatic Account Rebalancing among the variable
accounts to the allocation specified in Section 4a of the main
application.
/ / Month / / Quarterly / / Semi-Annually / / Annually
[NOTE: AUTOMATIC ACCOUNT REBALANCING AND DOLLAR COST
AVERAGING CANNOT BE IN EFFECT SIMULTANEOUSLY.]
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4c DOLLAR COST AVERAGING
Select one account from which to transfer money. Be sure you
have money allocated to this account in Section 4a.
Transfer $_______________________ [($100 minimum)]
EVERY: / / Month / / Quarter / / 6 Months / / 12 Months
FROM: [/ / Fixed Account / / Allmerica Money Market Fund ]
[THIS ACCOUNT CANNOT BE SELECTED IN THE ALLOCATION BELOW.]
[TO:
___________% 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 Growth Portfolio
___________% Select Growth and Income
___________% Fidelity Equity Income Portfolio
___________% Fidelity High Income Portfolio
___________% Investment Grade Income
___________% Allmerica Money Market
___________% Fixed Account
___________%
100 % TOTAL ]
5 INSURANCE
5a I WANT $______________ IN LIFE INSURANCE COVERAGE.
5b I WANT INSURANCE COVERAGE TO BE: (Choose one)
/ / Option 1 Level - Insurance coverage remains constant.
/ / Option 2 Adjustable - Insurance coverage changes with
the value of your policy.
/ / Option 3 Level - Cash Value Accumulation Test
5c I WANT THE FOLLOWING ADDITIONAL INSURANCE BENEFITS:
[ / / Waiver of payment upon disability
/ / Living benefits
/ / Other Insured Rider (Complete Supplementary Application)
/ / Guaranteed Insurability Rider $_________________________
/ / Term Rider and Amount $_____________________________
/ / Guaranteed Death Benefit Rider ]
6 BENEFICIARY
The Primary Beneficiary is the person or entity who will receive
the policy proceeds. The Contingent Beneficiary is the person or
entity who will receive the policy proceeds should the Primary
Beneficiary not survive the insured.
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Name of Primary Beneficiary Relationship to Insured
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Name of Contingent Beneficiary Relationship to Insured
If the beneficiary is a trust, please specify trust date.
M/_____ D/_____ Y/_______
7 REPLACEMENT OF OTHER CONTRACTS
WILL THE PROPOSED POLICY REPLACE ANY EXISTING ANNUITY OR LIFE
INSURANCE CONTRACT?
/ / Yes / / No
If yes, list company name and policy number.
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Total life insurance in force $____________________________.
8 INFORMATION ABOUT THE INSURED
8a I HAVE HAD AN ILLNESS OR INJURY DURING THE PAST SIX MONTHS THAT
HAS PREVENTED ME FROM WORKING FIVE CONSECUTIVE DAYS.
/ / Yes / / No If yes, please explain:
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8b PLEASE PROVIDE THE NAME OF LAST PHYSICIAN CONSULTED, DATE
AND REASON FOR CONSULTATION.
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8c DURING THE PAST THREE YEARS I 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:
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8d DURING THE PAST THREE YEARS I HAVE PARTICIPATED IN OR I
INTEND TO PARTICIPATE IN:
/ / Scuba diving / / Skydiving / / Motor racing
/ / Hang gliding or similar flying activity
8e DURING THE PAST THREE YEARS I HAVE FLOWN AS OR I INTEND TO
FLY AS A TRAINEE, PILOT OR CREW MEMBER.
/ / Yes / / No
8f DURING THE PAST YEAR, I HAVE SMOKED ONE OR MORE CIGARETTES.
/ / Yes / / No
8g I CURRENTLY USE:
/ / Cigars / / Pipe / / Chewing tobacco
/ / Other tobacco product
(Please specify)
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8h I WILL BE TRAVELING OUTSIDE OF THE UNITED STATES OR CANADA IN
THE NEXT SIX MONTHS:
/ / Yes / / No, If yes, please indicate country:
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[8i CURRENT EMPLOYMENT.
Name of Employer
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Occupation and Responsibilities
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[8j INCOME.
My annual earned income is $__________________________________
My annual unearned income is $__________________________________
My net worth is $__________________________________]
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9 TELEPHONE ACCESS
Unless I did not accept the Telephone Access privilege, I under-
stand 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 the withdrawal of funds from my account can-
not be transacted by telephone or fax instructions.
/ / I DO NOT accept this Telephone Access privilege.
10 INVESTOR CLASS
/ / ACCREDITED INVESTOR
As that term is defined in Section 230.501(a)(1) of the
Securities Act of 1933.
/ / QUALIFIED PURCHASER
As that term is defined in Section 2(9)(51) of the Investment
Company Act of 1940.
11 REMARKS
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ACKNOWLEDGEMENTS AND SIGNATURES
NOTICE TO ARKANSAS/NEW JERSEY/OHIO RESIDENTS ONLY:
"Any person who includes any false or misleading information on an
application for an insurance policy/certificate is subject to criminal
and civil penalties."
NOTICE TO COLORADO/KENTUCKY/MAINE/NEW MEXICO/
PENNSYLVANIA RESIDENTS ONLY: "Any person who knowingly and
with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any
materially false information or conceals for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent
insurance act, which is a crime and subjects such person to criminal
and civil penalties."
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 application containing false,
incomplete, or misleading information is guilty of a felony of the third
degree."
I acknowledge receipt of current Prospectuses describing the
[Allmerica Select] policy I am applying for, and the underlying Funds.
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 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 PREMIUM PAYMENTS.
It is agreed that:(1) The application consists of this application form,
the medical questionnaire and the supplemental application to apply
for insurance on family members, 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 premium is
paid during the lifetime of the proposed insured(s) and then only if the
proposed insured(s) has (have) not consulted or been treated by any
physician or practitioner of any healing art nor had any tests listed in
the application since its completion; but, if the premium is paid prior
to delivery of the policy and a conditional receipt is delivered by the
representative, insurance will be effective subject to terms of the con-
ditional 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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Signature of Second Insured or Spouse (if OIR)
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Signature of Owners (if other than Insured) Date
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Signed at City State
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Official Title/Capacity
FOR REGISTERED 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 or
approved by the Company were used.
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Signature of Registered Representative Date
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Print Name of Registered Representative TR Code/Reg Rep #
( ) ( )
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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
FOR HOME OFFICE USE ONLY
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