2023 Property Loss Notice (2) MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston, Massachusetts 02108-1904
(617)723-3800 Ma Only(800)392-6108, FAX(800)851-8424
5/6/2023
Form of Notice of Casualty Loss to Building
Under Mass. Gen. Laws, Ch.139, Sec.3B
YARMOUTH HEALTH DEPT
1146 ROUTE 28
SOUTH YARMOUTH MA 02664
Re: Insured: XIAXI LI AND YACHEN SHU
Property Address: 28 GARDINER LN. SOUTH YARMOUTH, MA 02664
Policy Number: 1581374
Type Loss: All Other Section I Losses
Date of Loss: 05/04/2023
Claim Number: 472534
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
E1 0 L O
MAY 1 1 2023
HEALTH DEPT.