13-030 (7) Safety Insurance 03
Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS Ch. 139 Sec. 3B
Building Commissioner or Board of Health or
Inspector of Buildings Board of Selectman
City Hall City Hall
NORTHAMPTON MA 01060 NORTHAMPTON MA 01060
Re: Insured(s): SARAH E SMITH&NANCY ALLEN
Property Address: 402 N KING ST,NORTHAMPTON MA 01060 D n
Policy Number: 0122274 ` {; _ D8
Claim Number: BOS00000931
Date of Loss: 09-08-2008
Company: Safety Insurance
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 313 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.
Brian Murphy,Adjuster 09/22/08
Safety Insurace Company
Homeowners Claims Unit
P.O. Box 55098
Boston, MA 02205-5098
Phone: (800)9511-2100x5172
Fax: (617)603-4899
CC012.001