189 LAFAYETTE STREET 7-7-22 CLAIM MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston,Massachusetts 02108-1904
(617)723-3800 Ma Only(8001392.6108.FAX(800)851-8424
7/16/2022
Form of Notice of Casualty Loss to Building
Under Mass. Gen. Laws, Ch.139, Sec.313 RECEIVED
SALEM HEALTH DEPT. JUL 2 5 2022
SALEM CITY HALL CITY OF SALEM
SALEM MA 01970 BOARD OF HEALTH
Re: Insured: SORKADH MUSTAFA& IRIDA MUSTAFA
Property Address: 189 LAFAYETTE ST.#2.SALEM. MA 01970
Policy Number: 1390167
Type Loss: Water Damage: Plumbing Systems
Date of Loss: 07/07/2022
Claim Number: 466436
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. 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