6 Randall Street 6-28-18 claim rJ C!
Butterworth & O'7oo�e, Inc.
RECEIVED
ADJUSTERS/APPRAISERS JUL 16 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
c laims(a)butterworthotoole.com
07/09/2018
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: Maria Amaral
Address: 6 Randall Street
Salem, MA 01970
Policy No.: 3154309
Loss of: 06/28/2018 Water/ Seepage
File or Claim No.: 87-1182
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,See.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
ylll"
Memher of
National Association of Independem Insuranee Adjusters