13 OLDE VILLAGE DRIVE 11-5-22 CLAIM MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston, Massachusetts 02108-1904
(617)723-3800 Ma Only(800)392-6108, FAX(800)851-8424
11/12/2022
Form of Notice of Casualty Loss to Building
Under Mass. Gen. Laws, Ch.139. Sec.3B
RECEIVED
SALEM HEALTH DEPT NOV 17 2022
SALEM CITY HALL
SALEM MA 01970 CITY OF SALEM
BOARD OF HEALTH
Re: Insured: THOMAS STANGA,JOHN &COURTNEY GRAY
Property Address: 13 OLDE VILLAGE DR, SALEM, MA 01970
Policy Number: 1573602
Type Loss: Water Damage:All Other Water Damage
Date of Loss: 11/05/2022
Claim Number: 468359
Claim has been made involving loss,damage or destruction of the above captioned property,which may either
exceed$1000.00 or cause Massachusetts General Laws. Chanter 143, section 6 to be applicable. If any
notice under Massachusetts General Laws. ChaAer 139. Section 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.
MPIUA Claims Division
CMA00021