10 BARR STREET - BUILDING JACKET� JD /�� �� -kz�
THEMORFOLKf�DEDHAMGROUP®
March 17, 2015
FORM OF NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B
Building Commissioner, or Inspector of Buildings
c/o City or Town Hall
93 Washington St.
Salem, MA 01970
Board of Health or Board of Selectmen
c/o City or Town Hall-
93 Washington St.
Salem, MA 01970
Fire Department or Arson Squad
c/o City or Town Hall
93 Washington St.
Salem, MA 01970
RE: Our File No.: P1590516
Insured: LAURENCE J BRENGLE
KIM W BRENGLE
Address: 10 BARR STREET, SALEM, MA
Policy No.: D507417
Loss Date: 03/16/2015
Loss Type: Building or Other Structure Damage
A claim has been made involving loss, damage or destruction of the above captioned property,
which may either exceed $1,000.00 or cause Mass. Gen. Laws, Ch. 143, Sec. 6 to be
applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct
it to my attention and include a reference to the captioned insured, location, policy number, loss
date and claim or file number.
If no reply is received from your office within ten days, we will assume you have no liens of any
type against this property, and the claim will be paid in our customary manner.
Sincerely,Michelle M. Roust
Senior Property Claims Examiner
1-800-688-1825 x1171
NORFOLK&DEDHAM MUTUAL FIRE INSURANCE CO. 222 Ames Street,P.O.Box 9109,Dedham,MA 02027-9109
DORCHESTER MUTUAL INSURANCE CO. Telephone:(800)688-1825
FITCHBURG MUTUAL INSURANCE CO. ® Fax:(781)329-1818