8 CROSS STREET - NOTICE 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
1/22/2022
Form of Notice of Casualty Loss to Building
Under Mass. Gen. Laws. Ch.139 Sec.36
SALEM BUILDING COMMISSIONER
SALEM CITY HALL
SALEM MA 01970
Re: Insured: JOSEPH SKOMURSKI
Property Address: 8 CROSS ST,SALEM, MA 01970
Policy Number: 1488226
Type Loss: Water Damage:All Other Water Damage
Date of Loss: 01/17/2022
Claim Number: 462900
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. Chapter 139. Section 313 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
_A JAN 28 A-M11 a48
JA