21 Buchanan Road 3-3-18 claim RECEIVED
MAR 12 2018
CITY OF SALEM
,l
Butterworth & 0' OCe, Inc. BOARD OF HEALTH
ADJUSTERS/APPR&SERS
FOR INSURANCE COMPANIES ONLY
P.O.BOX 8294
SALEM,MA 01971-8294
TEL. (978)741-5731
FAX (978)740-9109
claims@butterworthotoole coin
03/07/2018
FORM OF NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASS. GEN. LAWS, CH. 139, SEC. 311
TO:
EBuildingInspector & Salem Fire Department & Health Inspector
48 Layfayette Street 120 Washington Street 4th0 floor
Salem, MA 01970 Salem, MA 01970
RE: Insured: Timothy She
Address: 21 Buchanan Road
Salem, MA 01970
Policy No.: 1502693
Loss of: 03/03/2018 Wind
File or Claim No.: 086-0551
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 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
Member of
National Association of Independent Insumncc Adjusters