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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(800)851-8424
3/3/2012
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: WALTER B AND MARYANNE P MaILLr E �_
Property Address: 306 FOREST ST,NORTH AND VER, cqo
Policy Number: 1067581
Type Loss: Theft'
Date of Loss: 02/29/2012 'TOWN OF NORTH ANDOVER
Claim Number: 300278
HEALTH DEPARTMENT
Claim has been made involving loss,damage or destruction of the above captioned propert,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