8 CROSS STREET 1-17-22 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
1/22/2022
Form of Notice of Casualty Loss to Building
Under Mass.Gen. Laws. Ch.139 Sec.313 RECEIVED
SALEM HEALTH DEPT. JAN 3 1 2022
SALEM CITY HALL CITY OF SALEM
SALEM MA 01970 BOARD OF HEALTH
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 Chapter 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