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PQ Box 55098
Boston, MA 02205-5098
617-951-0600
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 Selectman
City Hall City Hall
NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845
-RE:. - Insured: STEPHEN. P. CAMMARAT. A and SUSAN E CAMMARATA
Property Address: 101 BRIDGES LANE, NORTH ANDOVER, MA
Policy Number: HMA 0113897
Claim Number: BOS00055802
Date of Loss: 3/14/2015
Company: Safety Indemnity Insurance Company
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, Chapter 143, Section 6 to be
applicable. If any notice under Mass. Gen. 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 number.
Jedd Canape Claim Examiner
Safety Insurance Company
Homeowners Claims Unit
P. 0. Box 55098
Boston, MA 02205-5098
Phone: (617) 951-0600 EXT 3524
Fax: (617) 531-8897
Email: JeddCatiane@Safetylnsurance.com
3/17/2015