17 BAY VIEW AVENUE 1-4-18 CLAIM Margetta Adjustment, Inc.
PROFESSIONAL ADJUSTERS AND PROPERTY APPRAISERS
.■ „ 82 Granite Street ;''° ���D
Fall River, MA 02720
® (508)67Fax�5 8)675(4660 508) 675-5326 _� 2 02018
personal
commercial *, OF SALEM
inland marine -.?.i:rARD OF HEALTH
FORM OF NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASS. GENERAL LAWS, CHAPTER 139, SECTION 3B
1/8/18
Attn: Health Inspector
Salem Board of Health
120 Washington Street, 4th Floor
Salem, MA 01970
RE: INSURED : Cynthia A. Nowak-Jerzylo & Raymond A. Jerzylo
MAIL LOCA: 17 Bay View Avenue, Salem, MA 01970
LOSS LOCA: 17 Bay View Avenue, Salem, MA 01970
POLICY NO: HOP0076506
CLAIM NO: CLM35623
DATE/LOSS : 1/4/2018
TYPE/LOSS : Freeze Up
FILE NO: M18-27890-FRZ
Claim has been made involving loss, damage, or destruction of the above
captioned property, which may either exceed $1, 000 . 00 or cause Mass .
General Laws , Chapter 143 , Section 6 to be applicable . If any notice under
Mass . General Laws , Chapter 139 , Section 3B is appropriate please direct it
to the attention of writer number,and
ddate lode loss type and file
reference of o e loss captioned
insured, location, Policy
number.
Sincerely,
l \
< I caused copies of this notice to be sent to the
On this date
persons named above at the addresses indicated above first class mail .
a request for a copy of a report.
Please note this is not