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Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
To: Building Commissioner or Board of Health or
Inspector of Buildings Board of Selectman
City Hall City Hall
NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845
RE: Insured:
Property Address:
Policy Number:
Claim Number:
Date of Loss:
Company:
ALLISON CHAPMAN and /O ANN WILLIAMS
39 FRANKLIN ST, NORTH ANDOVER, MA
HMA 0097343
BOS00037402
5/16/2013
Safety Indemnity Insurance Company
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 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 number.
Allan Leavitt Claim Examiner
Safety Insurance Company
Homeowners Claims Unit
P. O. Box 55098
Boston, MA 02205-5098
Phone: (617) 951-0600 EXT 3213
Fax: (617) 531-8891
Email: AllanLeavitt@Safetylnsurance.com
5/21/2013