Name: *

Address: *

Telephone Number: *

Mobile Number: *

Email Address: *

Name of the HPA affiliated club of which the employer is a member of the HPA: *

Please state a date from which you would like cover to be effective: *

Number of Staff employed for up to 6 full months: *

Number of Staff employed for up to 12 full months: *

Do you require a copy of the policy certificate to be forwarded for the purpose of confirming your employer status to the Home Office?*

if Yes, please advise to whom this should be sent:

Please tick this box to confirm that you are applying for this insurance as a private individual and are not engaged in polo as a commercial business or for financial gain.*

Please tick the box to confirm that you have read and understand the Keyfacts, Policy Wording and Lycetts Terms of Business and request Lycetts send you a quote. *

* Indicates a required field