8 HARBOR STREET - BUILDING INSPECTION �. 1
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WORCESTER INSURANCE COMPANY
120 Front Street, Suite 500 * Worcester, MA 01608-1408
DATE: 05/10/00
TO: Building Commissioner or Board of Selectmen or
Inspector of Buildings Board of Health
City Hall City Hall
Salem, MA 01970 Salem, MA 01970 �O\
RE: Insured: Harbor Street Property
Property Address: 39-41 &� Harbor Street
Policy Number: BO 1E2109
Loss of: 05/06/00 !L)
File or Claim Number: NO 049406
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, Ch. 139, Sec. 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.
David G. Vincent
Senior Claims Adjuster
On this date, I caused copies of this notice to be sent to the per named
above at the addresses indicated above by first class mail.
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Signature
Date S �/—I
A Member of The Harleysville Insurance Companies
WNS-251 CL(Ed. 5-95)
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