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Claim # 3048746
Advantage Claim Services Adjuster Assigned: G Guarente
522 Chickering Road #B
North Andover, MA 01845
Form of Notice of Casualty Loss to Building
Under Mass. Gen. Laws, Ch. 139, Sec. 3B
To: Building Commissioner Cit/ Board of Health or
Inspector of Buildings Board of Selectmen
Town Hall Town Hall
North Andover, MA 01845 North Andover, MA
Re: Insured: Robert Cerchiene
Property address: 173 Bridges Ln.
North Andover, MA 01845
Policy #: 3048746
Loss of: 2014/03/01
File or Claim No. AD 9975
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,_ Ch _139_Sec. _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.
G Guarente
Title: Adjuster
On this date, I caused copies of this notice to be sent to the persons
named at the addresses indicated above by first class mail.
4z,n� Attl�
04-30-14
Signature arld date