116 BOSTON STREET 12-30-17 CLAIM eREC EIVED
JAN 102013
Butterworth & 0'7oote, Inc. C11Y OF SALEM
BOARD OF HEALTH
ADJUSTERS/APPRALSERS
FOR INSURANCE COMPANIES ONLY
P.O.BOX 8294
SALEM,MA 01971-8294
TEL. (978)741-5731
FAX (978)740-9109
claims@butterworthotoole.com
01/03/2018
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: Heidi Staghan
Address: 116 Boston Street
Salem , MA 01970
Policy No.: 2506840
Loss of: 12/30/2017 Water/ Freeze Up
File or Claim No.: 086-0029
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.
Jack McKeon
Adjuster
Membernj
National Association or Independent Insurance Adastets