Service Request Form

LCU Account Number:

Example of Account # 1111111-1, or 0000000-1

Name on Account:

Service Address:

ZIP Code:

Phone Number:

Example of Phone Number: 239-111-1111


Requested Service:

Select a date from the calendar.
Select a date from the calendar.

Note: If you are unsure when you would like service to be re-connected, leave the Date Service Reconnect field blank. Once the date has been determined, please re-submit this form with reconnect date completed. Disconnection/Reconnection date must not land on a weekend or holiday. LCU requires 1-2 business day in advance notice for disconnection/reconnection of service