415 Lafayette Street 10-23-21 claim W. Springfield, MA ��� _ I��® Pittsfield, MA
(413)781-2897 � R E-C (888)881-4598
Quincy, MA Butler Worcester, MA
(617)479-2619 h r NOV 0 9 2021 (888)881-4598
Mattapoisett, MA k � Cape Cod&Islands
(508)758-6633 I CITY OF SALEM (888)881-4598
Rhode Island _ BOARD OF HEALTH Hartford, CT
(888)881-4598 BUTLER (888)881-4598
Building Commis '-oner or Board of Health or
Inspector of B dings Board of Selectmen
C/, NIA
City of Salem
1on Street 120 Washington Street
3r 4th Floor
S1970 Salem, MA 01970
Acords Attention: Records
COMPANY: Certain Underwriters at Lloyds, London c/o Vanguard Claims
Administration, Inc.
POLICY NUMBER: XSZ179336
CLAIM NUMBER: XS09290
INSURED: Robert Barrientos, Jr.
LOSS LOCATION: 415 Lafayette Street, Salem, MA
DATE OF LOSS: 10/23/2021
DESCRIPTION: Wind
OUR FILE NUMBER: P21-11907
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 3B,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 @georgebutleradj usters.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 4, 2021
209 Park Avenue,West Springfield,MA 01089