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109 ADAMS AVEU-A
/ 210/045.F-0012-OOOO.A
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MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston, Massachusetts 02108-1904
(617) 723-3800, Ma Only(800) 392-6108, Fax(617) 557-5675
03/23/01
Form of Notice of Casualty Loss to Building
Under Mass. Gen. Laws, Ch. 139, Sec.313
NORTH ANDOVER HEALTH DEPT.
NORTH ANDOVER TOWN HALL
NORTH ANDOVER MA 01845
Re: Insured: SHAMIN SHAHID
Property Address: 109 ADAMS AVE, NORTH ANDOVER, MA 01845
Policy Number: 0639151
Type Loss: Other Section I losses
Date of Loss: 02/26/01
Claim Number: 185102
Claim has been made involving loss, damage or destruction of the above captioned property,
which may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143,
Section 6 to be applicable. If any notice under Massachusetts General Laws, chapter 139,
Section 3 B 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
T OWN OF NORTH ANDOJ ,
BOARD OF HEALTH
MAR 3 0 2001
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