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NEW ENGLAND CLAIMS SERVICE, INC.
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P.O. BOX 345 100 CONIFER HILL DRIVE, SUITE 308 P.O. BOX 578
MANSFIELD, MA 02048 DANVERS, MA 01923 SHREWSBURY,
TEL. (508) 337-8058 MA 01545
I' .. (978) 777-9900 TEL. (508) 842-3995
FAX (508) 3395835 FAX (978) 774-9296 FAX (508) 842-7510
Form of Notice of Casualty Loss to Building
Under Mass. Gen. Laws, Ch. 139, Sec. 3D FEB 2 2 M
TO: Building Commissioner or Board of Health or
Inspector of Buildings Board of Selectmen
addresses
RE: INSURED
-PROPERTY ADDRESS
POLICY NO.. N-2 0 0 0
LOSS OF:
FILE OR CLAIM NO.:
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 3D
is appropriate, please direct it to the attention of [lie writer and include a reference to the
captioned insured, location, policy number, date of loss and claim or file number.
TITLE
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.
�/moi' lL3
SIG ATUF(E AND DATE
cc: Firg(ept .
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