11 CHURCH STREET, APT. G14 11-19-16 CLAIM MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston,Massachusetts 02108-1904
REEC ;VED (617)723-3800 Ma Oniv(8001392.6108,FAX(800)851-8424
1 1 12 212 0 1 fi
NOV 2 6 015
Form of Notice of Casualty Loss to Building
= ' Under Mass.Gen.Laws,Ch.139,Sec.3B
OF FIL-AJH
SALEM HEALTH DEPT.
SALEM CITY HALL
SALEM MA 01970
Re: Insured: ADITA VAZQUEZ
Property Address: 11 CHURCH STREET APT G14.SALEM,MA 01970
Policy Number: 1329403
Type Loss: Water Damage:All Other Water Damage
Date of Loss: 11/19/2016
Claim Number: 410415
Claim has been made involving loss,damage or destruction of the above captioned property,which may either
exceed$1000.00 or cause Massachusetts General1aws,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