11 CHURCH STREET, #112 6-13-09 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
6/18/2009
Form of Notice of Casualty Loss to Building
Under Mass.Gen.Laws,Ch.139,Sec.36
SALEM HEALTH DEPT.
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SALEM CITY HALL �JUN
SALEM MA 01970
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Re: Insured: JOSEPH SAMAN SKY
Property Address: 11 CHURCH ST UNIT 9112,SALEM,MA 01970
Policy Number: 0877671
Type Loss: Water Damage:All Other Damage Loss
Date of Loss: 06/13/2009
Claim Number: 264392
Claim has been made involving loss,damage or destruction of the above captioned propert,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