28 Surrey Road 2-2-18 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
2/9/2018
Form of Notice of Casualty Loss to Building
Under Mass. Gen. Laws,Ch.139 Sec.313 RECEIVE®
SALEM HEALTH DEPT. FEB 14 2018
SALEM CITY HALL CITY OF SALEM
SALEM MA 01970 BOARD OF HEALTH
Re: Insured: CAMILLE O'KEEFE
Property Address: 28 SURREY RD.SALEM,MA 01970
Policy Number: 1361073
Type Loss: Ice Dams
Date of Loss: 02/02/2018
Claim Number: 422462
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