9 1/2 ALBION STREET 3-18-17 CLAIM MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston,Massachusetts 02108.1904
(617)723.3800 Me Only(8001392-6108, FAX(8001851.8424
3`/2`1/2018
Form of Notice of Casualty Loss to Building R y C E f V E
Under Mass, Gen. Laws, Ch.139,Sec.313
MAR 2 6 2018
SALEM HEALTH DEPT. CITY OF SALEM
BOARD OF HEALTH
SALEM CITY HALL
SALEM MA 01970
Re: Insured: MICHAEL&TRACY KASZUBA
Property Address: 91/2 ALBION STREET,SALEM,MA 04970
Policy Number: 1248972
Type Loss: Water Damage:All Other Water Damage
Date of Loss: 03/18/2017
Claim Number: 426935
Claim has been made involving!oss,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 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