Residential Wood Burning Stove Evaluation

What is your first name?

What is your last name?

What is your email address?

What is the address where the wood burning stove is located?

Street Address Address Line 2 City State ZIP Code

Stove Information

What type of stove do you have in your home?

Freestanding Woodstove
Furnace Add-on
Fireplace Insert

What is the construction of the stove?

What is the primary purpose of the stove?

Is there floor protection under the stove?

Yes
No

What type of floor protection is in place?

Asbestos Millboard Covered with Metal
Metal
Stone/Brick

Is there wall protection?

Yes
No

What type of wall protection is in place?

Asbestos Millboard Covered with Metal
Metal
Stone/Brick

What is the make and model of the stove?

Is the stove U.L. (Underwriters' Laboratories) approved?

Yes
No

Chimney Type

What type of chimney does your stove have?

Factory
Masonry

How often is the stove checked for creosote build-up?

Semi-annually
Annually

What is the date of the stove's last professional cleaning?

What is the name of the company you used to clean the stove?

Does the pipe vent pass through a combustible partition?

Yes
No

What type of wall/ceiling pass through do you have for your wood stove?

Fire Clay Thimble
Stove Pipe
Insulated Metal Pipe
Listed Wall Pass Through

Does the pipe vent pass directly through the roof?

Yes
No

Are there any other heating units vented through this chimney?

Yes
No

Please provide a description of the other heating unit(s) vented through this chimney.

Is the stove vent system equipped with a heat reclaiming unit or a flue radiator?

Yes
No

Unit Clearances

Please enter the measurements, in inches, from the unit to the walls, ceiling, floor, etc... below.

1. How many inches is it from the side of the unit to the nearest wall?

2. How many inches is it from the rear of the unit to the wall?

3. How many inches is it from the top of the stovepipe to the ceiling?

4. How many inches is it from the bottom of the unit to the floor?

5. How many inches is it from the front of the unit to the front edge of the floor protection?

6. What is the size of stovepipe used for the chimney? (Inches)

7. What is the size of thimble or roof joist shield used? (Inches)

Do these distances comply with the stove manufacturer's standards?

Yes
No
Not sure

Fuel and Prevention Information

What type of fuel is used in this stove?

Wood
Coal

Is there a fire extinguisher in the room with the stove?

Yes
No

Is the fire extinguisher serviced in accordance with the manufacturer's guidelines?

Yes
No

Do you have a smoke alarm in operation in your home?

Yes
No

Please upload a picture of your stove.

Max. file size: 128 MB.

Please enter any additional remarks related to your wood burning stove below.

Consent*

Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.

Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.

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Residential Wood Burning Stove Evaluation

Stove Information

Chimney Type

Unit Clearances

Fuel and Prevention Information

Nat Worden

RiskRevu^TM Newsletter

Contact

Residential Wood Burning Stove Evaluation

Stove Information

Chimney Type

Unit Clearances

Fuel and Prevention Information

Nat Worden

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RiskRevuTM Newsletter

Contact

RiskRevu^TM Newsletter