386 Highland Avenue 12-26-20 claim RECEIVED
Butterworth & O'Tbofie, Inc. MAY Q 4 2021
ADJUSTERS/APPRAISERS CITY OF SALEM
FOR INSURANCE COMPANIES ONLY BOARD OF HEALTH
P.O.BOX 8294
SALEM,MA 01971-8294
TEL. (978)741-5731
FAX (978)740-9109
claimsfii butterworthotoole.com
04/30/2021
FORM OF NIO ICE OF CASUALTY LOSS TO BUILDING
UNDER MASS. GEN. LAWS, CH. 139, SEC.3B
TO:
Building Inspector & Salem Fire Dept & Health Inspector
City Hall 48 Layfayette Street 120 Washington St 4th floor
Salem, MA 01970 Salem, MA 01970 Salem, MA 01970
RE: 'Insured: `victoria Frasca
Address: 386_Faip-rla nd-Avenue
Salem, MA 01970
Policy No.: 3214194
Loss Y:2,s vr�:G 2U Water i Bacx iJp
File or Claim No.: 15-0363
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 Folev
Adjuster
Member of
National Association of Independent Insurance Adjusters