Insurance Submission Form

FFAM ID Number*


This is the 7 digit FFAM File Number.

How to Locate your FFAM ID Number
The FFAM ID Number is located on the letter you received from FFAM directly. It is listed as Our Account # on the letter as shown here.

Phone Number*


Phone Number we may reach you at with any questions we have

Policy Holder Name*


The Policy Holders Name

Insurance Company Name*


The name of your Insurance Company

Policy Number*


Your Policy Number as it appears on your Policy

Policy Period*

Starting Date of your Policy
Ending Date of your Policy

Claim Number


Claim Number received from your Insurance Company

Adjuster Name


The name of your adjuster

Adjuster Phone Number


The phone number of your Adjuster

Adjuster Fax Number


Your Adjusters Fax number if you received one

Your Preferred Email Address*


Your email address. A copy of this form will be sent to your email address given here
Authorization to correspond using the email address above
I authorize FFAM to correspond with me using the email address above


You may upload insurance information or documents here