18 RAYMOND ROAD - NOTICE OF CASUALTY LOSS MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston,Massachusetts 02108-1904
(617)723-3800 Ma Only(800)392-6108. FAX(800)851-8424
5/20/2021
Form of Notice of Casualty Loss to Building
Under Mass. Gen.Laws. Ch.139 Sec.3B
SALEM BUILDING COMMISSIONER
SALEM CITY HALL
SALEM MA 01970
Re: Insured: DOMINGO DOMINGUEZ
Property Address: 18 RAYMOND AVE,SALEM, MA 01970
Policy Number: 1260316
Type Loss: All Other Section I Losses
Date of Loss: 05/10/2021
Claim Number: 455815
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. Chap-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
Y 26 Am"'L :3 a
MAY