5 Gardner Street 1-5-17 claim MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston,Massachusetts 02108-1904
(617)723-3800 Ma Only(800)392-6108, FAX(800)851-8424
9/15/2018
Form of Notice of Casualty Loss to Building
Under Mass.Gen.Laws Ch.139,Sec.3B R E-C E I V E D
SEP 2 0 2018
SALEM HEALTH DEPT, CITY OF SALEM
SALEM CITY HALL BOARD OF HEALTH
SALEM MA 01970
Re: Insured: KATHLEEN WORTH
Property Address: 5 GARDNER STREET,SALEM, MA 01970
Policy Number: 1331836
Type Loss: Water Damage:All Other Water Damage
Date of Loss: 01/05/2017
Claim Number: 432218
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,Chaoter 143, section 6 I'd be applicable. If any
notice under Massachusetts General Laws, Chaater 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 Ciaims Division
CMA00021