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Form of Notice of Casualty Loss to Building
.y Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
TO: Building Commissioner or Board of Health or
Inspector of Buildings Board of Selectmen
Town of N. Andover ) ( Town of N. Andover
addresses
N. Andover, MA 01845 ) ( N. Andover, MA 01845
)
RE: Insured: Charles M. & Tatsia Dichiara
Property address: C43�.Merlilehead -Street--,,
N. Andover, MA
Policy No. HP1565948
Loss of 5/8/93 19
File or Claim No. WAP16267 Vandalism
I
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. 311
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.
Adjuster
Title:
On this date, I caused copies of this n6tice to be sent to the persons named above
at the addresses indicated above by first class mail.
PATRICK J. DONOVAN ASSOCIATES, INC. �f ^ , 6/2/93
P.O. BOX 110 Signature and date
WAKEFIELD MA 01880