27 Silver Street 4-27-19 claim Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
RECEIVED
To: Public Properties Department MAY 2 0 2019
120 Washington Street, 3rd Floor
SaiCi ii, MA 01970 CITY OF SALEM
BOARD OF HEALTH
RE: Insured: Luiz Quaresma
Property Address: 27 Silver Street
Company: Merrimack Mutual Fire Insurance Company
Policy/Claim Number: FP2619532, FP2619532
Date/Cause of Loss: 4/27/2019, Vehicle Damage
Our File Number: 37051-R
Claim has been made involving loss, damage or destruction of the above captioned property,
which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER
143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS,
CHAPTER 139, SECTION 313 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.
Ryan Werner, Ext. 116
On this date, I caused copies of this Notice to be sent to the persons named above at the
addresses indicated above by First Class Mail.
(fiti.- S IG if
Signa, 4 and Date
ANDERSON ADJUSTMENT CO., INC.
50 Nashua Road, Suite 303
PO Box 1098
Londonderry, NH 03053
Cc: Board of Health Salem Fire Department
120 Washington Street, 4th Floor 48 Lafayette Street
Salem, MA 01970 Salem, MA 01970