11 Winter Street 10-17-19 claim f InsuranceRECEIVED
joSa Safety
AUTO•HOME •BUSINESS OCT 31200
P.O. Box 55098
Boston MA 02205 CITY OF SALEM
617-951-0600 BOARD OF HEALTH
October 21, 2019
Building Commissioner or Inspector of Buildings
Fire Department or Arson Squad
Board of Health or Board of Selectman
City Hall
SALEM, MA 01970
Insured: ROBERT L CIOCIOLA and JANICE F_ MARTIN
Property Address: 11 WINTER STREET, SALEM MA
Policy Number: HMA0471766
Claim Number: BOS00093929
Date of Loss: 10/17/2019
Notice of Loss Under M.G.L. c. 139A 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-referenced 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, § 313, 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 at
617-951-0600 EXT 5164.
Sincerely,
Michelle Negip
Claim Examiner