150 LAFAYETTE STREET 12-19-25 CLAIM RECEIVED
Safety Insurance® JAN 0 2 2026
AUTO • HOME BUSINESS
Y`- CITY OF SALEM
BOARD OF HEALTH
December 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: LDMA067FE4
Insured(s): DANIEL DOMENICHELLO
Property Address: 150 LAFAYETTE STREET, SALEM, MA 01970
Policy Number: DMA2213515
Date of Loss: 12/19/2025
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
tiagodecar✓alho@safetyinsurance.com or by phone at 617-951-0600 extension 5192.
Sincerely,
Tiago De Carvalho
Property Field Adjuster
Visit us at www.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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