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NEW ENGLAND CLAIMS SERVICE, INC.
Reply To O Reply To ❑
100 CONIFER HILL DRIVE, SUITE 308 P. O. BOX 578
DANVERS, MA 01923 SIIREWSIIURY, MA 01545 - -
TEL: (508) 777-9900 TEL. (508) 842-3995
FAX (508) 774-9296 FAX (508) 842-7510
TOWN of r,nJI, Tf w�i
Form of Notice of Casualty Loss to Building fir`'' = ':
Under Mass. Gen_. Laws, Ch. 139 Sec 3D ! d
TO: Building Commissioner or
Inspector of Buildings
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addresses
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RE: INSURED 'T'b
Board of Health or
Board of Selectmen ,-__j
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PROPERTY ADDRESS _s' cf-
MY
POLICY NO.:, fit, 4 S 30 P 4S6
LOSS OF: _ ' ( %I 19--,--)
FILE OR CLAIM NO.: 'ids c2j5 9
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 the writer and include a reference to the
captioned insured, location, policy number, date of loss and claim or file number.
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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.
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SIGN A AND DATE
CC: Fire Dept.