ICE DAMS MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center'laza
Boston,Massachusetts 02108-1904
(617)723-3800 Ma Only(8001392-6108,FAX(800)851-8424
2/9/2018
Form of Notice of Casualty Loss to Building
Under Mass.Gen.Laws,Ch.139,Sec.313
SALEM BUILDING COMMISSIONER
SALEM CITY HALL
SALEM MA 01970
I
Re: Insured: CAM LLE O'KEEFE
Property Address: 28 SURREY RD,SALEM,MA 01970
Policy Number: 1361073
Type Loss: Ice Dams
Date of Loss: 02/02/2018
Claim Number: 422462
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 36 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