13 OLDE VILLAGE DR- CLAIM NOTICE MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston,Massachusetts 02108.1904
(617)723.3800 Me Only(800)392.6108,FAX(8001851-8424
8/2612023
Form of Notice of Casualty Loss to Building
Under Mass Gen. Laws Ch.139,Sec,3B
SALEM BUILDING COMMISSIONER
SALEM CITY HALL
SALEM MA 01970
Re: Insured: COURTNEY GRAY&JOHN GRAY AND
Property Address: 13 OLDE VILLAGE DR. SALEM. MA 01970
Policy Number: 1614566
Type Loss: Water Damage:All Other Water Damage
Date of Loss: 08/20/2023
Claim Number: 474638
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
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