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PQ Box 55098
Boston,MA 02205-5098
517-951-0600
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
N ANDOVER, MA 01845 N ANDOVER, MA 01845
RE: Insured: JAMES T ROONEY and KATHLEEN ROONEY
Property Address: 65 FERNCROFT CIR,N ANDOVER, MA
Policy Number: HMA 0382877
Claim Number: BOS00050221
Date of Loss: 2/15/2015
Company: 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.
Joshua Terenzoni Claim Examiner 2/20/2015
Safety Insurance Company
Homeowners Claims Unit
P. 0. Box 55098
Boston, MA 02205-5098
Phone: (617)951-0600 EXT 3287
Fax: (617) 531-6648
Email: JoshuaTerenzoni@Safetylnsurance.com