The Insurance Supermarket


Certificate/Proof of Insurance Request

Current Insurance Information
Insured's Name:
Contact Person:
Your Phone Number:

Type of Policy Coverage Requested
 Commercial General Liability
 Auto Liability
 Auto Physical Damage
 Umbrella/Excess  Workers Comp

Description of Operation/Job/Location

Certificate Holder:
Company Name:
State: Zip Code: 
Recipient Fax Number:
Date Certificate Needed:       Mail   Fax
Name Certificate Holder As:
 Loss Payee
 Requested for Job
   Additional Insured


Cancellation Note   # of days          

Plano General Insurance Agency
1150 East Park Blvd., Plano, TX 75074
Revised: June 06, 2003.