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