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City of Lynchburg

900 Church Street, Lynchburg, VA, 24504, US





DO NOT leave blanks anywhere in this document. If the City of Lynchburg receives this document with blanks it will be returned to the sender for correction.

Home/Property Owner: Make sure that you have been in contact with an Insurance Agent, and have their contact information, including email address to complete this form.

Section A
Completed by Home/Property Owner: Upon completion of this section, the home/property owner will then email it to their Insurance Agent of choice.

Section B
Completed by Insurance Agent: Upon completion of this section, the document will be forwarded to the home/property owner who will then complete Section E, along with uploading property photos on Pages 5 & 6.

Sections C & D

Section E
Completed by Home/Property Owner

Section F
Completed by Home/Property Owner: Upon completion of this section, along with Pages 5 & 6 the document will be electronically submitted to the City of Lynchburg.

Section G
Optional – Water Resources

Pages 5 & 6
Completed by Home/Property Owner
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Signature HereClick to Sign
Signature HereInsurance Agent Will Sign Here
Signature HereProperty Owner (Part 2) Will Sign Here
Signature HereWater Resources Will Sign Here

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