12 SHORE AVE_ NOTICE OF LOSS 6-20-25 IwoSafety Insurance°
AUTO.HOME.BUSINESS
June 22, 2025
Building Commissioner or Inspector of Buildings
Fire Department or Arson Squad
Board of Health or Board of Selectmen
City Hall
SALEM, MA 01970
RE: Claim Number: LHMA05BOF5
Insured(s): RICHARD URBANOWICZ
Property Address: 12 SHORE AVE, SALEM, MA 01970
Policy Number: HMA0621550
Date of Loss: 6/20/2025
Notice of Loss Under M.G.L. c. 139 § 3B
This communication shall serve as written notice pursuant to M.G.L. c. 139, § 3B that [Safety
Insurance Company] ("Safety") has received a claim involving loss, damage or destruction to a
building or other structure at the above-reference address which may either: (1) meet or exceed
$1,000; or (2) cause the condition or the building or other structure to render M.G.L. c. 143 § 6
applicable.
In accordance with M.G.L. c. 139, § 3B, if the city or town intends to initiate proceedings designed
to perfect a lien under Section 3B, M.G.L. c. 143, §9 or M.G.L. c. 111, § 127B, please notify Safety
of the same by certified mail. Kindly forward such notice to my attention, at the address indicated
above, and include with such notice a reference to the above-described insured, property address,
Policy number and claim number.
If you have any questions regarding this notice, please feel free to contact me directly by email at
LsaMonetfe@-Safetylnsurance.com or by phone at 6W-1351-2100extension 3420.
Sincerely,
Lisa Monette
Property Claims Field Adjuster
Visit us at w .safetyinsurance.com/claims for Frequently Asked Claims Questions
Safety Insurance P.O. Box 55098 Boston,MA 02205-5098 800-951-2100
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