11 CHURCH STREET, #308 10-5-09 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
1 01612 0 0 9
I.
Form of Notice of Casualty Loss to Building
Under Mass.Gen.Laws,Ch.139,Sec.313
SALEM HEALTH DEPT. J�"
SALEM CITY HALL OCT,
SALEM MA 01970
C17Y r•,-
SOARr-
Re: Insured: A JEAN RYAN
Property Address: 11 CHURCH UNIT 308,SALEM, MA 01970
Policy Number: 0756415
Type Loss: Water Damage:All Other Damage Loss
Date of Loss: 10105/2009
Claim Number: 267510
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 36 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