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Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
To: Building Commissioner or
Inspector of Buildings
1600 Osgood Street
North Andover, MA 01845
RE: Insured:
Property Address
Policy Number:
Date/Cause of Loss
File or Claim Number:
Raymond & Elizabeth Letourneau
700 Salem Street
HP0631328
4/1/2014, Water/Rain Seepage
29473-R
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 and
include a reference to the captioned insured, location, policy number, date of loss and claim or
file number.
Ryan Werner
On this date, I caused copies of this Notice to be sent to the persor s named above at the
addresses indicated above by First Class Mail.
Signatu ,e and Date
ANDERSON ADJUSTMENT CO., INC.
50 Nashua Road, Suite 303
PO Box 1098
Londonderry, NH 03053