194 Marlborough Road 12-31-17 claim RECEIVE® LaMarche Associates
5 North Road, P.O. Box 250
JAN 1 0 2018 Chelmsford, MA 01824
800-349-1525
CITY OF SALEM Fax: 978-256-8590
BOARD OF HEALTH
January 2, 2018
Building Commissioner/Inspector of Buildings
Salem, MA 01970-1063
Board of Health/Board of Selectmen
Salem, MA 01970-1063
NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B
Claim has been made involving loss, damage or destruction of the property captioned
below, 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 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, cause
of loss and LA file number.
Insured: Henry & Lorraine Bernard
Loss Location: 194 Marlborough Road
Salem, MA 01970-1063
Policy Number: HOA5745741
Date of Loss: 12/31/2017
Cause of Loss: Water
LA File Number: MA-2-33939
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.
Kevin Gabbett
Adjuster
LaM—hM1 Associates,I- B00-3i9-1515
Pa"1of1