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NORTH AivDOVER TEA 01845? i2n
January 03,2020
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INSURED: RAVI VANCHEESWARAN PHONE NUMBER: 800-280-0714
DATE OF LOSS: December 21,2019 FAX NUMBER: 866-447-4293
CLAIM NUMBER: 0572580116 RAW OFFICE HOURS: Mon-Fri 8:00 any -5:30 pm,
PROPERTY ADDRESS: 253 APPLETON ST NORTH Sat 8:00 am-2:00 pm
ANDOVER,MA
POLICY NO.: 000984130712
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Farm of Notice of Casualty Lass to Building
Under Mass.Gen.Laws.Oh I39.Sec.3 a
TO:
Building Commissioner or Board of Health or y.
Inspector of Buildings Board of Selectmen
CITY,TOWN HALL: North Andover/Treasurer;'Collector
ADDRESS: 120 Main Street
CITY%TONk,NIZIP CODE: North Andover,MA 01845
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 Klass.Gen.
Laws, is appropriate,please direct it to the attention of the undersigned and include a
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. 1§0
SIGNATURE AND DATE
ALISE WILSON
January 03,2020
- Copy: RAVI VANCHEESWARAN ARUNA ViSWADOSS
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