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February 10, 2015
DINELEY
CLAIMS
SERVICES
Town of North Andover
Building Commissioner
1600 Osgood Street
North Andover, MA 01845
FORM OF NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASS. GENERAL LAWS, CH. 139, SEC. 3B
INSURANCE COMPANY: Vermont Mutual
COMPANY INSURED: Elena Michelson
PROPERTY ADDRESS: 100 Kingston St, North Andover, MA
POLICY NUMBER: H012003354
DATE OF LOSS: 2/9/15
CAUSE OF LOSS: ice dam.
CLAIM NUMBER: HC205708
PROVIDING
SERVICES IN
NEW ENGLAND
NEW YORK
NEW JERSEY
PENNSYLVANIA
DELAWARE
MARYLAND
OHIO
VIRGINIA
AND
FLORIDA
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, Ch. 139, Sec. 3B is appropriate, please direct it to the attention of the
undersigned and include a reference to the above -captioned insured, location, policy number, date of
loss, and claim number.
If no reply is received from your office within ten days, we will assume that you have no lien of any type
against this property, and we will proceed to pay this claim in full.
Insurance Claims Services
Tel 877-302-0203 • Fax 877-245-4987
PO Box 479 • Waitsfield, V r 05673-0479
www.DineleyClaimsServices.com