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POBox55098
Boston,MA 02205-5098
617-951-0600
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: JOHN W SACHETTI
Property Address: 12 SALT WALL LN, SALEM, MA
Policy Number: HMA 0200578
Claim Number: BOS00060835
Date of Loss: 5/8/2015
Company: Safety Indemnity 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, Chapter 143, Section 6 to be
applicable.,If any notice-under Mass: Gen. Laws, Chanter 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.
Allan Leavitt Claim Examiner 5/12/2015
Safety Insurance Company
Homeowners Claims Unit
P. O. Box 55098
Boston, MA 02205-5098
Phone: (617) 951-0600 EXT 3213
Fax: _(6.17) 531-8891
Email AllanLeavitt@SafelyInsurance.com