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210/106.A-0016-0000.0
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THE PROVIDENCE MUTUAL FIRE INSURANCE COMPANY
FORM OF NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASS. GENERAL LAWS, CH. 139 SEC. 3B
To: BUILDING COMMISSIONER OR BOARD OF HEALTH OR
INSPECTOR OF BUILDINGS BOARD OF SELECTMEN
TOWN CLERK'S OFFICE
120 MAIN STREET
NORTH ANDOVER, MA 01845
RE: INSURED :Claire King
PROPERTY ADDRESS :409 Forest Street North Andover, MA 01845
POLICY NUMBER :HP3959019117
DATEF LOSS OSS .02/15/2015
CLAIM NUMBER :15-1142
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. INCLUDE A
REFERENCE TO THE CAPTIONED INSURED, LOCATION, DATE OF LOSS AND CLAIM OR FILE
NUMBER.
(� L&aQ aL, 11151
SIGNATURE DAT
PROVIDENCE MUTUAL FIRE INSURANCE COMPANY
P. O. BOX 6066-PROVIDENCE, RHODE ISLAND 02940
TEL. (401)827-1800
FAX(401)822-1921
EMAIL: CLAIMS a@PROVIDENCEMUTUAL.COM
ON THIS DATE, I CAUSED COPIES OF THIS NOTICE TO BE SENT TO THE
PERSONS NAMED AT THE ADDRESSES INDICATED ABOVE BY FIRST CLASS N
SIGNATURE DATE
CC: FILE
340 EAST AVENUE,WARWICK, RI 02886 + TEL: (401) 827-1800
MAILING ADDRESS: P.O. BOX 6066, PROVIDENCE, RI 02904
TOLL FREE: 1-877-763-1800 • FAX: (401) 822-1921