13 OLDE VILLAGE DRIVE - NOTICE LOSS MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston, Massachusetts 02108.1904
(617)723-3800 Ma Oniv(800)392-6108.FAX(800)851-8424
11/20/2021
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: 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. Char.-ter 143,,section 6 to be applicable. If any
notice under Massachusetts General Laws. Chanter 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
NORM'4 PIS=
NO