Page * of * Concept Special Risks Ltd www.special-risks.co.uk

CSR/APP/3

ASSURED’S NAME:

ASSURED’S DATE OF BIRTH: ASSURED’S NATIONALITY: ASSURED’S STATE OF RESIDENCE: FULL MAILING ADDRESS (including ZIP/Post Code where available). IF COMPANY PROVIDE REGISTERED ADDRESS BENEFICIAL OWNER (this should be completed if vessel is insured in a company nameor if the beneficial owner of the vessel is someone other than the Named Assured):

EFFECTIVE DATE FROM: ( mm/dd/yy) TO: (mm/dd/yy) 0.01hrs LST VESSEL NAME: HULL ID: LENGTH OVERALL:

MANUFACTURER/MODEL: YEAR BUILT: MODEL YEAR:

PURCHASE PRICE: DATE OF PURCHASE: PRESENT VALUE:

MAXIMUM SPEED:

VESSEL REGISTERED:

VESSEL FLAG:

COVERAGES WILL NOT BE PROVIDED UNLESS REQUESTED HEREUNDER COVERAGES LIMIT (US Dollar)

HULL PHYSICAL DAMAGE

TENDER/DINGHY

MEDICAL PAYMENTS (maximum ($50,000)

PERSONAL PROPERTY

TRAILER

BREACH OF WARRANTY (APPLICABLE LOSS PAYEE MUST BE DETAILED ON PAGE 4) THIRD PARTY LIABILITY

LIABILITY TO PAID CREW

COMMERCIAL PASSENGER LIABILITY

UNINSURED BOATERS (minimum $100,000)

NON-EMERGENCY TOWING

OTHER (please specify)

PLEASE TICK THE APPROPRIATE BOXES

PRIMARY POWER

SAIL TYPE OF

VESSEL

SAILBOAT

OUTBOARD MOTOR YACHT

INBOARD SPORTSFISHER

HULL MATERIAL: FIBREGLASS HOUSEBOAT

WOOD CATAMARAN

KEVLAR OTHER (give details)

CARBONFIBRE

FERROCEMENT

METAL

VESSEL ENGINE/OUTBOARD DETAILS

HP MANUFACTURER FUEL YEAR SERIAL NO#

#1

#2

DATE PURCHASED PURCHASE PRICE PRESENT VALUE

#1

#2

LAST SURVEYED (mm/dd/yy) ASHORE OR AFLOAT

Application Form

Cirque show and Equipment USA

Noahs XFAC9415K304 94 ft

Manuel Rebecchi

July 28,2023 July27,2024

Florida

310 whitfield ave. Sarasota,fl 34243

Custom line 2003 2004

1700000 July 28,2022 1,700,000

25 kt USA/ Fl USA

10,000

25,000

1,700,000

1,000,000

1,000,000

2,500

XX 1,000,000 / 1,000,000

X

X

07/12/2022

2000

2000

MTU

MTU

Diesel

Diesel

2004

2004

536.102-916

536.102-917

OEM

Both

Page 2 of 5 Concept Special Risks Ltd www.special-risks.co.uk CSR/APP/3

TENDER/DINGHY INFORMATION

MANUFACTURER YEAR HULL ID/SERIAL NUMBER LENGTH

TENDER/DINGHY ENGINE/OUTBOARD DETAILS

MANUFACTURER HP SERIAL NUMBER

TRAILER INFORMATION

MANUFACTURER YEAR BUILT DATE

PURCHASED

PURCHASE PRICE PRESENT

VALUE

SERIAL NUMBER

PRIMARY MOORING LOCATION OF VESSEL (INCLUDING ZIP/POST CODE WHERE AVAILABLE) BETWEEN JULY 1ST to NOV 1ST PLEASE SPECIFY WHETHER VESSEL WILL BE ASHORE/AFLOAT (MOORED)/OR ON A HOIST. IF YOU ARE UNABLE TO PROVIDE A ZIP/POST CODE, PLEASE ADVISE LONGITUDE & LATITUDE.

PLEASE ADVISE IF THIS VESSEL IS FITTED WITH MANUFACTURER RECOMMENDED FIRE PREVENTION/EXTINGUISHING EQUIPMENT (if no provide explanation) : YES NO

PLEASE DETAIL ANY ANTI-THEFT PRECAUTIONS WHICH ARE IN PLACE ALL WATERS TO BE NAVIGATED DURING THIS POLICY PERIOD (YOU MAY ATTACH AN ITINERARY) WILL THE VESSEL BE LAID UP (OUT OF USE) DURING THIS POLICY PERIOD – IF SO DETAIL EXACT DATES, LOCATION AND ADVISE WHETHER ASHORE OR AFLOAT.

# GENERAL INFORMATION

1

IS THIS VESSEL USED FOR FARE PAYING

PASSENGERS?

YES NO IF YES, NUMBER OF PASSENGERS PER TRIP

MAXIMUM:

AVERAGE:

NUMBER OF TRIPS PER YEAR

MAXIMUM:

AVERAGE:

2 IS THIS VESSEL CHARTERED TO OTHERS WITH A

CAPTAIN?

YES NO IF YES, COMPLETE CAPTAIN CHARTER SUPPLEMENTARY SHEET 3 DOES THIS APPLICANT EMPLOY PAID CREW YES NO IF YES, HOW MANY? 4 IS THIS VESSEL CHARTERED TO OTHERS WITHOUT

A CAPTAIN (BAREBOAT)?

YES NO IF YES, COMPLETE BAREBOAT CHARTER SUPPLEMENTARY SHEET 5 IS THIS VESSEL USED FOR WATERSKIING OR

DIVEBOAT CHARTER?

YES NO IF YES, PROVIDE DETAILS

6 IS THIS VESSEL USED FOR ANY OTHER

COMMERCIAL OR BUSINESS PURPOSES?

YES NO IF YES, PROVIDE DETAILS

Sea-doo 2019 YDV75105A919 10

N/A

Door lock and remote monitoring via AIS system

Gulf of mexico, south atlantic ocean from Florida to Bahamas,Puerto rico,USVI and BVI,Mexico

No

Page 3 of 5 Concept Special Risks Ltd www.special-risks.co.uk CSR/APP/3

# GENERAL INFORMATION CONTINUED

7 WILL THIS VESSEL BE OPERATED SINGLE

HANDEDLY AT NIGHT?

YES NO IF YES, ADVISE WHEN, WHERE AND HOW OFTEN?

8 DOES ANYONE RESIDE ABOARD THE VESSEL YES NO IF YES, FOR HOW LONG DURING THE POLICY PERIOD? 9 WILL THIS VESSEL PARTICIPATE IN ANY

RACES/REGATTAS/RALLYS/SPEED TRIALS DURING

THIS POLICY PERIOD?

YES NO IF YES, COMPLETE RACING SUPPLEMENTARY SHEET 10 WAS ANY INSURANCE DECLINED, CANCELLED OR

NON-RENEWED IN THE LAST 5 YEARS?

YES NO IF YES, PROVIDE DETAILS

11 HAVE YOU OR ANY NAMED OPERATOR BEEN

INVOLVED IN A LOSS IN THE LAST 10 YEARS

(INSURED OR NOT)

YES NO IF YES, PROVIDE DETAILS

12 HAVE YOU OR ANY NAMED OPERATOR BEEN

CONVICTED OF A CRIMINAL OFFENCE OR PLEADED

NO CONTEST TO A CRIMINAL ACTION?

YES NO IF YES, PROVIDE DETAILS

ALL OPERATORS MUST BE DETAILED – IF THERE ARE MORE THAN TWO OPERATORS PLEASE REQUEST ADDITIONAL CONCEPT OPERATOR SHEETS No. Full Name Date of Birth (mm/dd/yy) Violations/Suspensions (including Auto) in the last 5 years 1

Years of Boat Ownership Years of Operating Experience Boating Qualifications (for example USCG 100Ton)

Lengths and Manufacturers of Vessels previously owned or operated Have you been involved in a Loss in the last 10 years (insured or not)? If YES, please give details and amounts paid: Have you ever been convicted of a criminal offence or pleaded no contest? If YES, please give details 2 Full Name Date of Birth (mm/dd/yy) Violations/Suspensions (including Auto) in the last 5 years Years of Boat Ownership Years of Operating Experience Boating Qualifications (for example USCG 100Ton)

Lengths and Manufacturers of Vessels previously owned or operated Have you been involved in a Loss in the last 10 years (insured or not)? If YES, please give details and amounts paid: Have you ever been convicted of a criminal offence or pleaded no contest? If YES, please give details WARNING: THIS IS A NAMED OPERATOR ONLY POLICY

Everald Salesman

April 8, 1967 None

10 35

200 ton Costal master

88’ Azimut, 80’Ferreti

No

No

Alekhya Ramcharn

01/03/1989 None

0 2

Mate

88’ Azimut, 60 Astondoa

No

No

Page 4 of 5 Concept Special Risks Ltd www.special-risks.co.uk CSR/APP/3

LOSS PAYEE(S) (PLEASE PROVIDE NAME AND FULL MAILING ADDRESS) ADDITIONAL ASSURED’S REQUIRED – (PLEASE PROVIDE NAME, FULL MAILING ADDRESS AND REASON FOR REQUEST) PLEASE READ BEFORE SIGNING APPLICATION

1. This application will be incorporated in its entirety into any relevant policy of insurance where insurers have relied upon the information contained therein. 2. Any misrepresentation in this application for insurance may render insurance coverage null and void from inception. Please therefore check to make sure that all questions have been fully answered and that all facts material to your insurance have been disclosed, if necessary by a supplement to the application.

3. Fraud Statement – please see page 5 of this application form & initial the paragraph relevant to you to indicate that you have read and understood this. ASSURED SIGNATURE:

PRINT NAME AND STATE YOUR CONNECTION TO THIS POLICY IF YOU ARE NOT THE NAMED ASSURED/BENEFICIAL OWNER

SIGNATURE DATE:

PRODUCING BROKER

BROKER USE ONLY:

PLEASE PROVIDE SURPLUS LINES TAX FILING INFORMATION OR ADVISE IF NOT APPLICABLE (LICENSE NUMBER WILL SUFFICE) Cirque show & Equipment LLC,

310 Whitfield ave.

Sarasota,Fl 34243

None

Manuel Rebecchi

Page 5 of 5 Concept Special Risks Ltd www.special-risks.co.uk CSR/APP/3

Applicable in California

For your protection, California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. California Insurance Frauds Prevention Act 1871.2

Applicable in Florida and Idaho

Any person who Knowingly and with the intent to injure, Defraud, or Deceive any Insurance Company Files a Statement of Claim Containing any False, Incomplete or Misleading Information is Guilty of a Felony*

*In Florida – Third Degree Felony

Applicable in Indiana

A person who knowingly and with intent to defraud an insurer files a statement of claim containing false, incomplete, or misleading information commits a felony. Applicable in Nevada

Pursuant to NRS 686A.291, any person who knowingly and wilfully files a statement of claim that contains any false, incomplete, or misleading information concerning a material fact is guilty of a felony.

Applicable in New Hampshire

Any person who, with purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided by RSA 638:20. Applicable in New Jersey

Any person who knowingly and with the intent to defraud any insurance company or other persons, files a 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, subject to the criminal prosecution and civil penalties Applicable in New York

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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Applicable in Ohio

Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Applicable in Oklahoma

WARNING: Any person who knowingly and with the intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony

Applicable in Pennsylvania

Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and payment of a fine of up to $15,000.

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