11 CHURCH STREET, #507 10-25-14 CLAIM MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston, Massachusetts 02108-1904
(617)723-3800 Ma Onlv(800)392-6108, FAX(8001851.8424
11/812014
Form of Notice of Casual Loss to Building
9
Under Mass.Gen.Laws, Ch.139, Sec.3B
SALEM HEALTH DEPT.
SALEM CITY HALL
SALEM MA 01970
Re: Insured: MARY ZAWACKI
Property Address: 11 CHURCH STREET#507, SALEM,MA 01970
Policy Number: 1248909
Type Loss: Water Damage:All Other Water Damage
e 9 9
Date of Loss: 10125/2014
Claim Number: 327383
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,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