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210/068.0-0002-0000.0 --
LGUM ANERICAN INSURMCE COMPANIES®
PERSONAL LINES DIVISION
8 VISTA DRIVE
SOUTH LYME,CT 063766-0701
203/434-6500
FAX 203/434-0520
MAILING ADDRESS:
P.O.BOX 701
SOUTH LYME,CT 06376-0701
TO: ( ) Building Commissioner or Inspector of
_ Buildings
Board of Health or Board of Selectman
( ) Fire Department
b� �S
RE: Insured: y 4
Z/
Property Address:
Policy Number:
Loss of
Claim Number:
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 , Sec. 3B is appropriate please direct it to the
attention of the writer and include reference to the
captioned insured, location, policy number, date of loss, and
claim number.
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.
Date: 143DII� Adjuster
GREAT AMERICAN INSURANCE COMPANY•AMERICAN NATIONAL FIRE INSURANCE COMPANY•AMERICAN ALLIANCE INSURANCE COMPANY•AGRICULTURAL INSURANCE COMPANY
SUBSIDIARIES OF AMERICAN FINANCIAL CORPORATION