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December 18, 2018
Yarmouth Town Hall
1146 Route 28
South Yarmouth, MA 02664
FORM OF NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASS. GENERAL LAWS, CH. 139, SEC. 3B
INSURANCE COMPANY: Providence Mutual
COMPANY INSURED: Donna Belliveau
PROPERTY ADDRESS: 17 Bliscott Avenue, South Yarmouth, MA 02664
POLICY NUMBER: HP 0066590 16
DATE OF LOSS: December 16, 2018
CAUSE OF LOSS: Water
CLAIM NUMBER: 180000007374
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,VT 05673-0479
www.DineleyClaimsServices.com