3 VARNEY STREET 2-5-23 CLAIMForm of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
To: Building Commissioner
Salem, MA 01970
RE: Insured: Mary Fittante
Property Address: 3 Varney Street
Company: Merrimack Mutual Fire Insurance Company
Policy/Claim Number: HP11037181, CLM17586
Date/Cause of Loss: 2/5/2023, Frozen Pipes
Our File Number: 41809-M
Claim has been made involving loss, damage or destruction of the above captioned property,
which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER
143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS,
CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and
include a reference to the captioned insured, location, policy number, date of loss and claim or
file number.
Mike Peterson, Ext. 115
On this date, I caused copies of this Notice to be sent to the persons named above at the
addresses indicated above by First Class Mail.
Signature and Date
ANDERSON ADJUSTMENT CO., INC.
50 Nashua Road, Suite 303
PO Box 1098
Londonderry, NH 03053
Cc: Health Department
Fire Department