11 CHURCH STREET, APT. G14 3-18-15 CLAIM MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
^n Boston,Massachusetts 02108-1904
�R �+ (617)723-3800 Ma Only(800)392-6108,FAX(800)851.8424
101712015
Form of Notice of Casualty Loss to Building
C1iY �� SALE' } Under Mass.Gen.Laws Ch.139 Sec,3B
H�ALTN
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: Ice Dams
Date of Loss: 03/18/2015
Claim Number: 400838
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 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