13 OLDE VILLAGE DRIVE 12-13-25 CLAIM MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston,Massachusetts 02108.1904
(6171723.3800 Ma Only(800)392.6108, FAX(800)851-8424
12/20/2025
Form of Notice of Casualty Loss to Building
Under Mass. Gen. Laws Ch.139,Sec.313 RECEIVE
JAN 02 2026
SALEM HEALTH DEPT. CITY OF SALEM
SALEM CITY HALL BOARD OF HEALTH
SALEM MA 01970
Re: Insured: COURTNEY GRAY AND JOHN GRAY AND
Property Address: 13 OLDE VILLAGE DR. SALEM. MA 01970
Policy Number: 1688505
Type Loss: Water Damage:All Other Water Damage
Date of Loss: 12/13/2025
Claim Number: 488910
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