Insurance Policy Compliance Checklist Form
Use this form to review policy details, confirm compliance items, record gaps or exceptions, and assign follow-up actions.
Policy & Holder Information
Policyholder or Organization Name
*
Policy Number or Reference
*
Insurance Provider or Company Name
*
Policy Type
*
Auto
Home
Health
Life
Business
Other
Policy Effective Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Policy Expiration Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Policy Review Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Compliance Checklist
Policy is active and current
*
Yes
No
Premium payments are up to date
*
Yes
No
Required endorsements are attached
*
Yes
No
Coverage limits meet internal requirements
*
Yes
No
Exclusions have been reviewed
*
Yes
No
Certificates or proof of coverage are on file
*
Yes
No
Any gaps or exceptions identified
Coverage, Exceptions & Follow-up
Current Compliance Status
*
Compliant
Partially Compliant
Non-Compliant
Needs Review
Summary of Missing Items or Exceptions
Corrective Action Required
Responsible Reviewer / Department
*
Target Completion Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reviewer Notes
Submit Checklist
Should be Empty: