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Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
To: Building Inspector
1600 Osgood Street
North Andover, MA 01845
RE: Insured: Geraldine M. Dwyer
Property Address: 148 Main Street, Unit F543
Policy Number: HP1701182
Date/Cause of Loss: 10/13/2015, Damage to Door from Fire Dept.
File or Claim Number: 32722-P
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.
Pat Garrett
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.
1A A
Signature and to
ANDERSON ADJUSTMENT CO., INC.
50 Nashua Road, Suite 303
PO Box 1098
Londonderry, NH 03053