4 Pyburn Avenue 8-12-18 claim ` RECEIVE®
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ADJUSTERSIAPPRAISERS CITY OF SALEM
FOR INSURANCE COMPANIES ONLY BOARD OF WEALTH
P.O.BOX 8294
SALEM,MA 01971-8294
TEL. (978)741-5731
FAX (978)740-9109
claimsabutterworthotoole.com
08/13/2018 T
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: Lisa Cote
Address: 4 Pyburn Avenue
Salem, MA 01970
Policy No.: 2531862
Loss of: 08/12/2018 Water
File or Claim No.: 87-1287
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.
Patrick Davis
Adjuster
rl�
Member of
National Association of Independent Insurance Adjusters