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PO Box 55098
Boston, MA 02205
Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
To: Building Commissioner or
Inspector of Buildings
City Hall
NORTH ANDOVER, MA 01845
Board of Health or
Board of Selectman
City Hall
NORTH ANDOVER, MA 01845
RE: Insured: ELLEN BENEDICT
Property Address: 16 EDGELAWN AVE UNIT 4, NORTH ANDOVER, MA
Policy Number: HMA 0109596
Claim Number: BOS00066573
Date of Loss: 12/22/2015
Company: Safety 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.
Maria Rivas Claim Examiner
Safety Insurance Company
Homeowners Claims Unit
P. O. Box 55098
Boston, MA 02205-5098
Phone: (617) 951-0600 EXT 3324
Fax: (617) 502-2846
Email: MariaRivas@Safetylnsurance.com
12/28/2015
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