46 BUTLER STREET 3-2-18 CLAIM RECEIVED
MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION JUN 12 2018
Two Center Plaza CITY OF SALEM
Boston,Massachusetts 02108.1904 BOARD OF HEALTH
f617)723-3800 Ma Only(800)392.6108. FAX(800)851.8424
6/6/2018
Form of Notice of Casualty Loss to Building
Under Mass.Gen. Laws,Ch.139,Sec.36
SALEM HEALTH DEPT.
SALEM CITY HALL
SALEM MA 01970
Re: Insured: GUSTAVO GOMEZ
Property Address: 46 BUTLER ST.SALEM, MA 01970
Policy Number: 1319467
Type Loss: Windstorm Other than Hurricane or Tornad
Date of Loss: 03/02/2018
Claim Number: 429660
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