13 OLDE VILLAGE DRIVE 11-16-21 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
11/20/2021
Form of Notice of Casualty Loss to Building RECEIVED
Under Mass.Gen. Laws. Ch.139. Sec.36
IVUV ei 0 LuGI
CITY OF SALEM
SALEM HEALTH DEPT. BOARD OF HEALTH
SALEM CITY HALL
SALEM MA 01970
Re: Insured: THOMAS STANGA,JOHN&COURTNEY GRAY
Property Address: 13 OLDE VILLAGE DR, SALEM, MA 01970
Policy Number: 1573602
Type Loss: All Other Section I Losses
Date of Loss: 11/16/2021
Claim Number: 461943
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. Cha:,,ter 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