93 JACKSON STREET 7-28-08 CLAIM -"sacorporated 1985
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P.O. 330X 345 �- ''`
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MANSFIELD,MA 02048 ti H DANVERS, MA 01923
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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 Selectmen
RE: Insured: N a
Property Address:
Policy Number:
Date/Cause of Loss: ? o�
File or Claim Number.
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 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 or
file number.
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.
Clai s Adjuster Dat