22 Foster Street 3-2-18 claim RECEIVED
MAR 12 2010
(/ CITY OF SALEM
BOARD OF HEALTH
Butterworth & OlboCe, Inc.
AUJUSTF-RS/APPR.4ISFRS
FOR INSURANCE COMPANIES ONLY
P.O.BOX 8294
SALEM,MA 01971-8294
TEL. (978)741-5731
FAX (978)740-9109
c l a i m sg b utterw o rth oto o f e.com
03/08/2018
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: David Fitzpatrick
Address: 22 Forster Street
Salem, MA 01970
Policy No.: 2372969
Loss of: 03/02/2018 Wind
File or Claim No.: 85-0484
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.
Vicki Gardner
Adjuster
.Rr F.01
Member of
National Association or Independent Insurance Adjusters