107-109 Loring Avenue 4-15-18 MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston, Massachusetts 02108.1904
(617)723.3800 Ma Only(800)392.6108, FAX(800)851.8424
5/812018
Form of Notice of Casualty Loss to Building RECEIVED
Under Mass Gen Laws Ch.139 Sec.3B
MAY 1 1 2018
SALEM HEALTH DEPT. CITY OF SALEM
SALEM CITY HALL BOARD OF HEALTH
SALEM MA 01970
Re: Insured: NELSON TRINIDAD
Property Address: 107-109 LORING AVE. SALEM, MA 01970
Policy Number: 0637285
Type Loss: Water Damage:All Other Water Damage
Date of Loss: 04/15/2018
Claim Number: 428927
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 Chanter 143 section 6 to be applicable. If any
notice under Massachusetts General Laws Chapter 139. Section 3B is appropriaie, 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