11 CHURCH STREET, #112 6-20-12 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
6/22/2012
Form of Notice of Casualty Loss to Building
Under Mass. Gen. Laws,Ch.139,Sec.36
SALEM HEALTH DEPT,
SALEM CITY HALL
SALEM MA 01970
JUN 2 8 z01z
Re: Insured: JOSEPH SAMANSKY 3Oq. .1_ ariL
Property Address: 11 CHURCH ST UNIT#112,SALEM.MA 0�1�6DF HEALTH
Policy Number: 0877671
Type Loss: Water Damage: Plumbing Systems
Date of Loss: 0612012012
Claim Number: 302516
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