21 Buchanan Road 1-5-18 claim A
Butterworth & O'Toole, Inc. RECEIVED
ADJUSTERS/APPRAISERS JAN 10 2018
FOR INSURANCE COMPANIES ONLY CITY OF SALEM
P.O.BOX 8294 BOARD OF HEALTH
SALEM,MA 01971-8294
TEL. (978)741-5731
FAX (978)740-9109
clai ms(dtbutterworthotoole.com
01/05/2018
i
FORM OF NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B
TO:
Building Inspector & Salem Fire Department & Health Inspector
City Hall 48 Layfayette Street 120 Washington Street 4th
floor
Salem, MA 01970 Salem, MA 01970 Salem, MA 01970
RE: Insured: Timothy
Address: 21 Buchanan Road
Salem , MA 01970
Policy No.: 1502693
Loss of. 01/05/2018 CAT FREEZE-UP/BURST PIPE
File or Claim No.: 086-0076
Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed
51,000.00 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 writer and include a reference to the captioned
insured, location, policy number, date of loss and claim or file number.
If no reply is received from your office within ten days, we will assume you have no liens of any type against this
property and we will recommend to the insuring company that this claim is paid.
Jack McKeon
Adjuster
4y V
1�II I
National Association of Independent Insurance Adjusters