3 Harrod Street 1-10-18 claim ) 61
Butterulorth & O'�toofe, Inc.
ADJUSTERS/APPRAISERS RECEIVED
FOR INSURANCE COMPANIES ONLY
P.O.BOX 8294 JAN 1 8 2013
SALEM,MA 01971-8294 CITY OF SALEM
TEL. (978)741-5731 BOARD OF HEALTH
FAX (978)740-9109
claims(a),butterworthotoole com
01/16/2018
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: Barbara Osika
Address: 3 Harrod Street
Salem, MA 01970
Policy No.: 3004330
Loss of. 01/10/2018 Ice Dam
File or Claim No.: 086-0186
Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed
S1,000.00 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 4
insured, location, policy number, date of loss and claim or file number. VV
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 d
Men,b,,of
National Association of Independent Insurance Adjusters