Document 6471882

WOOD BURNING STOVE QUESTIONNAIRE
NAME OF INSURED ____________________________ POLICY NUMBER ___________________________
We have completed an inspection report that shows the insured has a wood burning stove.
Please provide the following information and return this form. Thank you.
STOVE TYPE Freestanding Woodstove ____
Please Check
Furnace Add-On____
Fireplace Insert ______
Other _______________________________________ (please specify)
Manufacturer ___________________
Model __________________
Year Installed ___________________
Is the unit certified by a testing laboratory? (Provide name of laboratory) __________________
INSTALLED BY
Insured ___________
Contractor _________
Not known____________
Did a Fire or Building Inspector inspect and approve the stove installation? __________
HEATING USAGE
How many hours per week when in use? _____________
How many cords used Annually? _____________________
Materials used other than cord wood? _________________
CHIMNEY
The Chimney used with the woodstove is:
______ An EXISTING fireplace chimney
Chimney exterior is:
_______ Frame
_______ Masonry
_______ Masonry with inner metal Chimney Pipe
_____METAL Chimney installed for the woodstove, ______ Other (Please describe below)
___________________________________________________________________
How often is chimney cleaned? ______________ When last cleaned? ___________
Last chimney fires? (approximate month/year) _______________________________
ASH REMOVAL
How often are the ashes removed for the stove? _____________________________
GENERAL
How many inches away from combustibles material is stove located?___________
INFORMATION
Is the stove placed on a non-combustible surface (such as an insulated stoveboard or masonry surface)?
Is there a smoke detector in the room or area where the stove is used? _________
Is there a fire extinguisher in the room or area where the stove is used? _________
Is the woodstove the primary source of heat?______ if no, what is? __________________________
P.O. Box 1618, Santa Ana, CA 92702
TEL 888.474.7500 • FAX 714.560.7873
DIAGRAM
Using the most appropriate diagrams for pipe clearance and stove clearance, give actual measurements
in inches.
PIPE CLEARANCE
Measuring from pipe to wall, and from pipe to ceiling.
B
C
A
A
inches
B
C
inches
inches
STOVE CLEARANCE
Measuring from side of stove to wall, and back of stove to wall.
F
D
G
E
D
E
inches
inches
F
G
inches
inches
HEARTH CLEARANCE
Measuring from side of stove having the stove door, give distance to edge of floor protection.
H
inches
P.O. Box 1618, Santa Ana, CA 92702
TEL 888.474.7500 • FAX 714.560.7873