16 Lafayette Place 4-16-18 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
4/19/2018
Form of Notice of Casualty Loss to Building
Under Mass. Gen. Laws, Ch.139,Sec.3B RECEIVED
SALEM HEALTH DEPT. APR $ 5 2018
SALEM CITY HALL CITY OF SALEM
SALEM MA 01970 BOARD OF HEALTH
Re: Insured: EDWARD SCIALDONI AND PATRICIA SCIALDONI
Property Address: 16 LAFAYETTE PLACE,SALEM,MA 01970
Policy Number: 1434348
Type Loss: Water Damage:All Other Water Damage
Date of Loss: 04/16/2018
Claim Number: 428198
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,Chanter 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