14 COUSINS STREET 10-17-22 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
1111212'-2:_
Form of Notice of Casualty Loss to Building
Under Mass. Gen. Laws. Ch.139. Sec.3B
RECEIVED
SALEM HEALTH DEPT. NOV 1 Z 2022
SALEM CITY HALL
SALEM MA 01970 CITY OF SALEM
BOARD OF HEALTH
Re: Insured: MICHELLE ARPIN
Property Address: 14 COUSINS ST. SALEM, MA 01970
Policy Number: 1432482
Type Loss: All Other Section I Losses
Date of Loss: 10/17/2022
Claim Number: 468426
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. Chapter 143. section 6 to be applicable. If any
notice under Massachusetts General Laws, Chapter 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