11 CHURCH STREET, #112 7-4-11 CLAIM MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston,Massachusetts 02108-1904
(617)723-3800 Ma Only(800)392-6108.FAX(8001851-8424
7/612011
Form of Notice of Casualty Loss to Building
Under Mass.Gen.Laws,Ch.139, Sec.313 RECEIVED
SALEM HEALTH DEPT, JUN 12 2011
SALEM CITY HALL
SALEM MA 01970 CITY OF SALEM
BOARD OF HEALTH
Re: Insured: JOSEPH SAMANSKY
Property Address: 11 CHURCH ST UNIT#112,SALEM, MA 01970
Policy Number: 0877671
Type Loss: Water Damage:All Other Damage Loss
Date of Loss: 07/04/2011
Claim Number: 290595
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
C MAD0021