18 Weatherly Drive #3 1-8-18 claim J RECEIVED
Butterworth & O'?ooCe, Inc. JAN 16 2018,
CITY OF SALEM
ADJUSTFRSIAPPRAISFRS BOARD OF HEALTH
FOR INSURANCE COMPANIES ONLY
P.O.BOX 8294
SALEM,MA 01971-8294
TEL. (978)741-5731
FAX (978)740-9109
claims(c_ilbutterworthotoo le.com
01/08/2018
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: Marcia Kamin
Address: 18 Weatherly Drive #3
Salem , MA 01970
Policy No.: 2376702
Loss of: 01/08/2018 CAT FREEZE-UP/BURST PIPE
File or Claim No.: 84-0091
Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed
81,000.00 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 Tobin
Adjuster
01
Member n(
National Association of Independent Insurance Adjusters