4 CEDAR HILL ROAD 2-27-05 CLAIM BUTTERWORTH & 01TOOLE, INC.
P.O.BOX 8294
SALEM,MA 01971-8294
ADJUSTERS/APPRAISERS
FOR INSURANCE COMPANIES ONLY
TELEPHONE(978)741-5731 FAX(978)740-9109
March 01, 2005
FORM OF NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B
TO: Building Commissioner or Board of Health or
Inspector of Buildings Board of Selectmen
City/Town Hall City/Town Hall
ADDRESSES
Salem, MA 01970 Salem, MA 01970
RE: Insured: Margaret A. Fucillo
Address. 4 Cedar HillRoad
_ MAR o 2005
Salem, MA 01970 CIN OF SALEM
BOARD OF HEALTH
Policy No. : HP1662413
Loss of : 2/27/05
File or Claim No. : 54-0457
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.
Patrick Tobin
Adjuster