225 Jefferson Avenue 6-22-20 claim 96,n
utterulort 0'7o'ole, Inc, RECEIVED
ADJUSTERS/APPRAISERS
FOR INSURANCE COMPANIES ONLY JUN O ZOZO
P.O.BOX 8294 CITY OF SALEM
SALEM,MA 01971-8294 BOARD OF HEALTH
TEL.. (978)741-5731
FAX (978)740-9109
claims@butterworthotoole.com
06/23/2020
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: James Richmond
Address: 225 Jefferson Avenue
Salem. MA 01970
Policy No.: 2092184
Loss of: 06/22/2020 Water
File or Claim No.: 05-0465
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.
John Foley
Member of
National Association of Independent Insurance Adjusters