18 Raymond Avenue 6-26-20 claim MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston,Massachusetts 02108.1904
(617)723-3800 Ma Oniv(800)392.6108.FAX(800)851-8424
7/9/2020
Form of Notice of Casualty Loss to Building
Under Mass. Gen. Laws Ch.139. Sec.313
RECEIVED
SALEM HEALTH DEPT. JUL 15 2020
SALEM CITY HALL
CITY OF SALEM
SALEM MA 01970
BOARD OF HEALTH
Re: Insured: DOMINGO DOMINGUEZ
Property Address: 18 RAYMOND AVE, SALEM, MA 01970
Policy Number: 1260316
Type Loss: Water Damage:All Other Water Damage
Date of Loss: 06/26/2020
Claim Number: 448967
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
GMA00021