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210/044.0-0009 0000.0 - - -
1
PATRICK J. DONOVAN ASSOCIATES, INC.
"CLAIM AND LOSS ADJUSTMENTS" gpr. �rj C'.';';r ,`j
P.O. Box 110
Wakefield, MA 01880
(617) 245-5540 JUN 2 9 SI-3
I �
FORM' OF NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASS . GEN. LAWS . CHP. 139, SEC. 3B
TO: Building Commissioner or
Inspector of Buildings
City or Town Hall
RE : Insured: n
Property Address : 5- 1 Nd . A-n lvty-, Mt�-
Policy Number: 1D 15D\4 30i
Loss Type :
I -i
Date of Loss : to- ) 3 - 98
Our File Number: W Af cp0 36
Claim has been made involving loss, damage or destruction of the above-
captioned property, which may either exceed $1 , 000 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 file number.
Adjuster
Donovan Associates, Inc .
Wakefield, MA
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 .