36 Palmer Street 3-13-20 MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
RECEIVED
c 1� Two Center Plaza
n EC E I V E D Boston,Massachusetts 02108-1904
MAR 2 4.,2020 (6171723-3800 Ma Only(800)392-6108,FAX(800)851-8424
3/1712020
Cl-1 Y OF SALEM Form of Notice of Casualty Loss to Building
BOARD OF HEALTH
Under Mass.Gen. Laws. Ch.139, Sec.36
SALEM HEALTH DEPT.
SALEM CITY HALL
SALEM MA 01970
Re: Insured: JOSE SANTOS
Property Address: 36 PALMER STREET,SALEM.MA 01970
Policy Number: 1200932
Type Loss: Water Damage: Plumbing Systems
Date of Loss: 03/13/2020
Claim Number: 446531
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. Char)ter 143 section 6 to be applicable. If any
notice under Massachusetts General Laws. Chapter 139. Section 313 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