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?
What type of stove do you have in your home?
What is the construction of the stove?
What is the primary purpose of the stove?
Is there floor protection under the stove?
What type of floor protection is in place?
Is there wall protection?
What type of wall protection is in place?
What is the make and model of the stove?
Is the stove U.L. (Underwriters' Laboratories) approved?
What type of chimney does your stove have?
How often is the stove checked for creosote build-up?
What is the date of the stove's last professional cleaning?
MM slash DD slash YYYY
What is the name of the company you used to clean the stove?
Does the pipe vent pass through a combustible partition?
What type of wall/ceiling pass through do you have for your wood stove?
Does the pipe vent pass directly through the roof?
Are there any other heating units vented through this chimney?
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?
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?
Fuel and Prevention Information
What type of fuel is used in this stove?
Is there a fire extinguisher in the room with the stove?
Is the fire extinguisher serviced in accordance with the manufacturer's guidelines?
Do you have a smoke alarm in operation in your home?
Please upload a picture of your stove.
Please enter any additional remarks related to your wood burning stove below.
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.