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BUTTERWORTH & O'TOOLE, INC.
ADJUSTERS/APPRAISERS
FOR INSURANCE COMPANIES ONLY
P.O. BOX 238, NEWTONVILLE, MA 02160 TELEPHONE (617) 969-6370
n 0 V 13 I nn ( FAX (617) 969-3135
Form of Notice of Casualty Loss to Building
Under Mass. Gen. Laws, Ch. 139, Sec. 3B
T0; Building Commissioner or Board of Heal'tWor
Inspector of Buildings Board of Selectmen
Tom C-) 11a.Q.R ) ( To 0 n fi t cep
addresses
n OLD Due r i INI n
RE: Insured:
Property Address:
(l C�.►1 dam- rnr>,' o i � �-�
Po 1 i cy No.
Loss of _ b-� g5 (qui C1C1 RC�'C1
File or Claim No. 1L0 — a 3 14
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 approrriate, please direct it to the attention of the writer
and inc ude 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 be paid.
�2ob.Prt L, I
Adjuster