5 Oliver Street 10-27-21 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
10/31/2021
Form of Notice of Casualty Loss to Building
Under Mass. Gen. Laws, Ch.139, Sec.3B E-CEI V ED
NOV 16 2021
SALEM HEALTH DEPT. CITY OF M2 LEM
SALEM CITY HALL BOARD OF HEALTH
SALEM MA 01970
Re: Insured: JAMES SHACKELFORD, LOUIS WESTERMAN
Property Address: 5 OLIVER ST, SALEM, MA 01970
Policy Number- 1536744
Type Loss: Windstorm Other than Hurricane or Tornad
Date of Loss: 10/27/2021
Claim Number: 460235
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