193 North Street 10-17-19 26&-'
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Butterwort O'Too ex .Inc. RECEIVED
ADJUSTERS/APPRAISERS O C i 2 8 2019
FOR INSURANCE COMPANIES ONLY
P.O.BOX 8294 CITY OF SALEM
SALEM,MA 01971-8294 BOARD OF HEALTH
TEL. (978)741-5731
FAX (978)740-9109
claims(a)butterworthotoo le.com
10/22/2019
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: Richard D Lemon
Address: 193 North Street
Salem. MA 01970
Policy No.: 2160913
Loss of: 10/17/2019 Wind
File or Claim No.: 99-093 8
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.
Michael Herbert
7
Member of
National Association of Independent Insurance Adjusters