322 Jefferson Avenue 1-5-18 claim MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston,Massachusetts 02108.1904
(617)723.3800 Me Only(8001392.6108,FAX(800)851.8424 I
1/17/2018
Form of Notice of Casualty Loss to Building Under Mass Gen Laws Ch.139.Sec.36 RECEIVED f
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JAN 2 2 2018 j
SALEM HEALTH DEPT. CITY OF SALEM
SALEM CITY HALL BOARD OF HEALTH
SALEM MA 01970
Re: Insured: OSCAR BEGIN
Property Address: 322 JEFFERSON AVE.,SALEM.MA 01970
Policy Number: 1415384
Type Loss: Freezing
Date of Loss: 01/05/2018
Claim Number: 421774
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
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