5 OLIVER STREET - CLAIM NOTICE 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
SALEM BUILDING COMMISSIONER
SALEM CITY HALL
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
Nora