11 BERRYWOOD LANE 6-23-21 CLAIM RECEIVED
Butterworth & O'Toofe, Inc. JUL 0 7 2021
ADJUSTERS/APPRAISERS FOR INSURANCE COMPANIES ONLY
SOC;Ty �ALEM
OF HEALTH
P.O.BOX 8294
SALEM,MA 01971-8294
TEL. (978)741-5731
FAX (978)740-9109
claims(a.butterworthotoole.com
06/29/2021
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 Lafayette Street 120 Washington St 4th floor
Salem, MA 01970 Salem, MA 01970 Salem, MA 01970
RE: Insured: Ro egg ig ero
Address: 11 Berrvwood Lane
Salem, MA 01970
Policy No.: 3038838
Loss of: 06/23/2021 Water/Burst Pipe
File or Claim No.: 17-0537
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, Chanter 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.
James Reilly
Adjuster
Member of
National Association of Independent Insurance Adjusters