7 Gardner Street 12-20-18 claim RECEIVED
JAN 0'2 2019
MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza CITY OF SALEM
Boston,Massachusetts 02108-1904 BOARD OF HEALTH
(617)723-3800 Ma Only(800)392-6108.FAX(8001851-8424
12/26/2018
Form of Notice of Casualty Loss to Building
Under Mass.Gen.Laws,Ch.139, Sec.3B
SALEM HEALTH DEPT
SALEM CITY HALL
SALEM MA 01970
Re: Insured: JUAN CAMELO
Property Address: 7 GARDNER STREET,SALEM,MA 01970
Policy Number: 1419304
Type Loss: Water Damage:All Other Water Damage
Date of Loss: 12/20/2018
Claim Number: 434625
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 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