13 FIRST STREET - BUILDING INSPECTION 13 Fi �sT ST
Liberty Mutual® Liberty Mutual Insurance
New England Region Central Property Unit
INSURANCE 75 Sylvan Street
Danvers,MA 01923
Tel:(800)566-0323
May 12,2015
City of Salem
Attn:Building Inspector
93 Washington St
Salem,MA 01970
Re: Property Address: 131st St 131, Salem,Ma 01970
Policy Number: H6521823679440
Underwriting Company: LM Insurance Corporation
Claim Number:031632586-0001
Date of Loss: 2/26/2015
Attn: Town/City Official
Pursuant to M.G.L. c. 139, 5 313, please be aware that a homeowners insurance claim has been made
involving loss, damage or destruction of the above captioned property, which may either exceed
$1,000.00 or causes the condition of a building or other structure to render Mass. General Laws, Ch.
143, 5 6 applicable. You are required to notify Liberty Mutual by certified mail in accordance with
Mass. General Laws Ch. 175, 599, if you intend to initiate proceedings designed to perfect alien
pursuant to Mass. General Laws, Ch. 139, 5 3A & B, or Mass. General Laws, Ch. 143, 5 9, or Mass.
General Laws,Ch. 111, 5 127B.
This letter should not be construed as a waiver or estoppel of any of the terms, conditions or
defenses afforded by the policy or applicable law.
Please direct your notice to the attention of the undersigned and include a reference to the above
captioned property address,policy number,claim number,and date of loss.
Sincerely,
Liberty Mutual Support
Liberty Mutual Insurance
New England Region Central Property Unit
1-800-566-0323
POBOX55098
Boston,MA022055098
817-951-0000
Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
To: Building Commissioner or Board of Health or
Inspector of Buildings Board of Selectman
City Hall City Hall
SALEM, MA 01970 SALEM, MA 01970
RE: Insured: LAURA J LANES and SCOTT F LANES
Property Address: 13 1 ST ST UNIT B-2, SALEM, MA
Policy Number: HMA 0395113
Claim Number: BOS00059148
Date of Loss: 2/26/2015
Company: Safety Insurance Company
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, Chanter 143, Section 6 to be
applicable. If any notice under Mass. Gen. 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 number.
Daniel Olsen Claim Examiner 4/14/2015
Safety Insurance Company
Homeowners Claims Unit
P. O. Box 55098
Boston, MA 02205-5098
Phone: (617) 951-0600 EXT 3323
Fax: (617) 531-2762
Email: Danie101sen@Safetylnsurance.com