6 1/2 ROSLYN STREET - BUILDING INSPECTION ' \ OSS ,� s
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NEW ENGLAND CLAIMS SERVICE, INC.
365 Broadway
Lynnfield, MA 01940
Form of Notice of Casualty Lass to Building
Under Nass Gen. Laws Ch. 139 Sec. 3D
TO: Building Commissioner or Board of Health or
Inspector of Buildings Board of Selectmen
addresses
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RE: INSURED: �^ ��txa �S�Za..i�
PROPERTY Y ADDRESS: " 6 t/z Si w lS-r/y�
POLICY NO. :
LOSS OF: 19 _
FILZ OR CLAIM f NO. : t W33
Claim has been made involving loss , da.-,age 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 . Can. Laws Chapter 139 Section 3D 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.
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On this date, I caused copies of this notice to be sent to the
Pe--sons named above at the addresses indicated above by first class Mail-
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Date Signed
WilsonJone5 RECIP!ENT—RETAIN WHITE COPY, RETURN Pr:' CO°
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