57R Lawrence Street 11-2-18 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
11/8/2018
Form of Notice of Casualty Loss to Building
Under Mass.Gen.Laws.Ch.139,_Sec.3B
SALEM HEALTH DEPT.
SALEM CITY HALL
SALEM MA 01970
Re: Insured: MIGUEL MARI FIORENTINO&LUISA MOORE
Property Address: 57R LAWRENCE ST.,SALEM,MA 01970
Policy Number: 0771917
Type Loss: Windstorm Other than Hurricane or Tornad
Date of Loss: 11/02/2018
Claim Number: 433674
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, Charter 143_section 6 to be applicable. If any
notice under Massachusetts General Laws. Chanter 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
N 0 V 2' 3520-13
CITY OF SALEM
CnRC C- Ij