9 Cloutman St_Claim MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston, Massachusetts 02108.1904
(617)723.3800 Me Only(8001392.6108. FAX(8001851.8424
11/19/2022
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: MICHAEL W AND KATHLEEN M SICOTTE
Property Address: 9 CLOUTMAN STREET,SALEM. MA 01970
Policy Number: 1187759
Type Loss: Vehicle Damage
Date of Loss: 11/17/2022
Claim Number: 468513
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
0