8 1/2 ALLEN STREET 5-8-18 CLAIM MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston,Massachusetts 02108-i904
(617)723-3800 Ma Only(800)392-6108, FAX(8001851-8424
8/9/2018
Form of Notice of Casualty Loss to Building
Under Mass.Gen.Laws, Ch.139. Sec.313
RECEIVED
SALEM HEALTH DEPT. AUG 14 2018
SALEM CITY HALL CITY OF SALEM
SALEM MA 01970 BOARD OF HEALTH
Re: Insured: IBRAHIM HAMZA
Property Address: 81/2 ALLEN STREET,SALEM. MA 01970
Policy Number: 1111017
Type Loss: Other Physical Damage
Date of Loss: 05/08/2018
Claim Number: 431155
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 36 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