Claim of Loss MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston,Massachusetts 02108-1904
(617)723-3800 Ma Only(800)392-6108,FAX(8001 851-8424
11120/2018
Form of Notice of Casualty Loss to Building
Under Mass.Gen.Laws.Ch.139,Sec.3B
YARMOUTH BUILDING DEPT
1146 ROUTE 28
SOUTH YARMOUTH MA 02664
Re: Insured: BRANDON PAUL PETKAUSKOS
Property Address: 53 FRANKLIN STREET EXT.WEST YARMOUTH,MA 02673
Policy Number: 1332337
Type Loss: Water Damage:All Other Water Damage
Date of Loss: 11/12/2018
Claim Number. 433948
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
CMA00021