24 Fowler Street 12-29-17 claim J �
Butterworth & Ol'bote, Inc.ADJUSTERS/APPRAISERS RECEIVED
FOR INSURANCE COMPANIES ONLY
P.O.BOX 8294 JAN 18 2018
SALEM,MA 01971-8294
TEL. (978)741-5731 CITY OF SALEM
FAX (978)740-9109 BOARD OF HEALTH
claims@butterworthotoole.com
01/15/2018
FORM OF NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B
I
i
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: John J Kozlowski
Address: 24 Fowler Street
i
Salem, MA 01970
Policy No.: 2050800
Loss of: 12/29/2017 Boiler
File or Claim No.: 086-0014
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.
Jack McKeon
Adjuster
Mentbo n(
National Association of Independent Insurance Adjusters