16 PURITAN ROAD 4-24-23 CLAIM Phone. 978-632 2660 lax: 9 78-632-2 6 62
RECEIVED
MAY 0 2 2023
�'RUDEE�U Ar IUSTAIE N`P SERVICE
P.O.Boer 7 CITY OF`SALEM
Gardner,MA 01440 BOARD OF HEALTH
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Notice of Casualty Loss of Buildin
Under Massachusetts General Laws, Chapter 139, Section 3B
04/27/2023
Building inspector
93 Washington Street
Salem,MA 01970
Board of Health
93 Washington Street
Salem,MA 01970
Fire Department
Dept. of Records
48 Lafayette Street
Salem,MA 01970
Insured: Dylan Haupert
Claimant:
Date of Loss: 04/24/2023
Type of Loss: Water
Loss Location: 16 Puritan Road,Salem,MA 01970
Policy No: 1564780
File No.: 23-20306
Claim No.: 0030062510
Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed
1 000.00 or cause "Mass. Gen. Laws Chapter 143 Section 6" to be applicable. If any notice under "Mass. Gen. Laws,
Chapter 139, Section 3B"is appropriate, please direct it to the writer and include a reference to the captioned insured, location,
policy number,date of loss,and file or claim number.
Claim has been made involving loss, damage or destruction of the above-captioned property,which may exceed $5000.
If any notice under Massachusetts General Laws, Charter 175, Section 97A is appropriate, please direct it to the
attention of this writer and include a reference to the above-captioned insured,location,policy number,date of loss and
claim number.
On this date,1 cause copies of this notice to be sent to the person(s)named above at the address indicated by first class mail.
Sincerely,
C 0_
Elena Bourassa
Claims Adjuster
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