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City of Lynchburg

sdcandm@lynchburgva.gov

900 Church Street, Lynchburg, VA, 24504, US

434-455-3800

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SURVEY NOT REQUIRED

DISCLAIMER:

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
N/A

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
03/02/2024
Signature HereProperty Owner (Part 2) Will Sign Here
03/02/2024
Signature HereWater Resources Will Sign Here
03/02/2024

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