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103 Water Damage Loss 2016 MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston,Massachusetts 02108-1904 161 71 723-3800 Ma Only 18001392-6108,FAX(8001 851-8424 Form of Notice of Casualty Loss to Building Under Mass.Gen.Laws.Ch.139,Sec.3B HEALTH DEPT. PUCHALSKI MUNICIPAL BUILDING 212 MAIN STREET NORTHAMPTON MA 01060 Re: Insured: SONIYA M PATEL Property Address: 103 DUNPHY DRIVE. FLORENCE.MA 01062 Policy Number: 1334414 Type Loss: Water Damage:Plumbing Systems Date of Loss: 0911912016 Claim Number: 409296 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 010021 912712016 MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston,Massachusetts 02106.1904 16171 723-3800 Ma Only(8001392-6108,FAX 18001851-8424 Form of Notice of Casualty Loss to Building Under Mass.Gen.Laws,Ch.139,Sec.3B NORTHAMPTON HEALTH DEPT. 212 MAIN STREET NORTHAMPTON MA 01060 Re: Insured: SONIYA M PATEL Property Address: 103 DUNPHY DRIVE,FLORENCE,MA 01062 Policy Number: 1334414 Type Loss: Water Damage:Plumbing Systems Date of Loss: 0911912016 Claim Number: 409296 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 bapplicable.ble .t If the notice under Massachusetts General Laws Chapter 139 Section 3B is appropriate,please 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 00021 9/2712016