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210/091._ 0-0027-0000.0
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AMERICAN CLAIMS SERVICE AWPfHXW
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MULTI-LINE ADJUSTERS 5
BUILDING COMMISSIONER OR BOARD OF HEALTH OR
INSPECTOR OF BUILDINGS BOARD OF SELECTMAN
120 Main St.
N. Andover, MA 01845
RE: INSURED: Pauline Boutin
51
PROPERTY ADDRESS: =, 5rbe� y ��` l" ifirr� 4MA..
POLICY NUMBER: H0 04006180
LOSS OF: 8/6/03, Severe water leak in kitchen
FILE/CLAIM NUMBER 23888 PD
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 file
number.
Craig Gillespie
Claims Representative
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.
Unless we hear from you within the next 10 days, we will not be
obligated to pay any portion of this claim to you.
August 29, 2003
Date
7 KIMBALL LANE, BUILDING C, LYNNFIELD, MASSACHUSETTS 01940
TELEPHONE (781) 245-9516 - FAX: (781) 245-1077