60 ORNE STREET 5-24-24 CLAIM
95 OLD RIVER ROAD, ANDOVER, MA 01810 | P: 800.225.0770 | ANDOVERCOMPANIES.COM
MERRIMACK MUTUAL FIRE INSURANCE COMPANY | BAY STATE INSURANCE COMPANY | CAMBRIDGE MUTUAL FIRE INSURANCE COMPANY
Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
To: Building Commissioner
Salem, MA 01970
RE: Insured: Elena McKone
Property Address: 60 Orne St
Company: Bay State Insurance Company
Policy Number: HP14071761
Claim Number: CLM40524
Date/Cause of Loss: 5/24/2024, Fire
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.
Erik Hayes
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
Cc: Health Department
Fire Department