6 Hawthorne Boulevard 10-26-21 claim W. Springfield, MA Pittsfield, MA
(413)781-2897 (888)881-4598
Quincy, MA Worcester, MA
(617)479-2619B (888)881-4598
Mattapoisett, MA Cape Cod&Islands
(508) 758-6633 (888)881-4598
Rhode Island Hartford, CT
(888)881-4598 BUTLER (888)881-4598
Building Commissioner or Board of Health or R C E I VE D
Inspector of Buildings Board of Selectmen
City of Salem City of Salem NOV 0 4 2021
120 Washington Street 120 Washington Street
3rd Floor 4th Floor CITY OF SALEM
Salem, MA 01970 Salem, MA 01970 BOARD OF HEALTH
Attention: Records Attention: Records
COMPANY: Certain Underwriters at Lloyds, London c/o Vanguard Claims
Administration, Inc.
POLICY NUMBER: XSZ181875
CLAIM NUMBER: XS09224
INSURED: Fatima Mitchell
LOSS LOCATION: 6 Hawthorne Blvd, Salem, MA
DATE OF LOSS: 10/26/2021
DESCRIPTION: Water
OUR FILE NUMBER: P21-11829
To Whom It May Concern:
Claim has been made involving loss, damage, or destruction of the above captioned property which
may either exceed $1,000, or cause Massachusetts General Law, Chapter 143, Section 6, to be
applicable. If any notice under Massachusetts General Law, Chapter 139, Section 313, is appropriate,
please direct it to the attention of this writer and include a reference to the captioned insured,
location,policy number, company claim number, date of loss, and claim or file number.
Sincerely,
John Schillizzi
Claims Adjuster
P—(978) 818-5453
F—617-470-1740
JohnS@georgebutleradjusters.com
On this date, I caused copies of this notice to be sent to the persons named above at the address
indicated above, by first class mail.
Secretary
November 1, 2021
P.O. Box 1557, Mattapoisett,MA 02739