15 CHASE STREET 1-14-20 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
1/17/2020
Form of Notice of Casualty Loss to Building
Under Mass.Gen.Laws Ch.139, Sec.36 RECEIVED
JAN 2 3 2020
SALEM HEALTH DEPT CITY OF SALEM
SALEM CITY HALL BOARD OF HEALTH
SALEM MA 01970
Re: Insured: ALDEA&JAMIE POTORSKI
Property Address: 15 CHASE STREET,SALEM, MA 01970
Policy Number: 1020290
Type Loss: All Other Section I Losses
Date of Loss: 01114/2020
Claim Number: 445373
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 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