2 Pierce Avenue 12-5-19 MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston,Massachusetts 02108-1904
(617)723-3800 Ma Only(8001392-6108,FAX(8001851-8424
12/14/2019
Form of Notice of casualty Loss to auuaing Under Mass.Gen.Laws Ch.139 Sec.36 RECEIVED
DEC 19 2019
SALEM HEALTH DEPT.
CITY OF SALEM
SALEM CITY HALL BOARD OF HEALTH
SALEM MA 01970
Re: Insured: TINA BURBINE
Property Address: 2 PIERCE AVE,SALEM, MA 01970
Policy Number: 1016377
Type Loss: Water Damage:All Other Water Damage
Date of Loss: 12/05/2019
Claim Number: 444773
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. Cha;Ater 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