11 CHURCH STREET, #308 11-25-14 CLAIM MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston, Massachusetts 02108-1904
(617)723-3800 Ma Only(8001392-6108, FAX(8001851-8424
12/19/2014
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
Re: Insured: A JEAN RYAN
Property Address: 11 CHURCH UNIT 308,SALEM, MA 01970
Policy Number: 0756415
Type Lass: Water Damage: Plumbing Systems
Date of Loss: 11/25/2014
Claim Number: 328290
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,Chanter 143, section 6 to be applicable. If any
notice under Massachusetts General Laws,Chanter 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