36 Palmer Street 12-19-19 MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston,Massachusetts 02108-1904
(617)723-3800 Ma Only(800)392-6108,FAX(800)851-8424
12/23/2019
Form of Notice of Casualty Loss to Building
Under Mass.Gen.Laws. Ch.13� 9ic.3B RECEIVED
DEC 2 7 2019
SALEM HEALTH DEPT,
SALEM CITY HALL CITY OF SALEM
SALEM MA 01970 BOARD OF HEALTH
Re: Insured: JOSE SANTOS
Property Address: 36 PALMER STREET,SALEM, MA 01970
Policy Number: 1200932
Type Loss: Water Damage: Plumbing Systems
Date of Loss: 12/19/2019
Claim Number: 444936
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