18 Raymond Avenue 5-10-21 claim MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston, Massachusetts 02108-1904
(617)723.3800 Ma Oniv(800)392.6108.FAX(800)851-8424
5/20/2021
Form of Notice of Casualty Loss to Building
Under Mass.Gen. Laws. Ch.139. Sec.313
RECEIVE®
SALEM HEALTH DEPT. MAY 2 4 2021
SALEM CITY HALL CITY OF SALEM
SALEM MA 01970 BOARD OF HEALTH
Re: Insured: DOMINGO DOMINGUEZ
Property Address: 18 RAYMOND AVE, SALEM, MA 01970
Policy Number: 1260316
Type Loss: All Other Section I Losses
Date of Loss: 05/10/2021
Claim Number: 455815
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)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