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Residential Wood Burning Stove Evaluation
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What is your first name?
What is your first name?
What is your last name?
What is your last name?
What is your email address?
What is your email address?
What is the address where the wood burning stove is located?
What is the address where the wood burning stove is located?
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Stove Information
What type of stove do you have in your home?
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 construction of the stove?
Cast Iron
Sheet Metal
Plate Steel
Not Sure
What is the primary purpose of the stove?
What is the primary purpose of the stove?
Primary Heat
Supplemental Heat
Occasional Heat
Cooking
Is there floor protection under the stove?
Is there floor protection under the stove?
Yes
No
What type of floor protection is in place?
What type of floor protection is in place?
Asbestos Millboard Covered with Metal
Metal
Stone/Brick
Is there wall protection?
Is there wall protection?
Yes
No
What type of wall protection is in place?
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?
What is the make and model of the stove?
Is the stove U.L. (Underwriters' Laboratories) approved?
Is the stove U.L. (Underwriters' Laboratories) approved?
Yes
No
Chimney Type
What type of chimney does your stove have?
What type of chimney does your stove have?
Factory
Masonry
How often is the stove checked for creosote build-up?
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 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?
What is the name of the company you used to clean the stove?
Does the pipe vent pass through a combustible partition?
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?
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?
Does the pipe vent pass directly through the roof?
Yes
No
Are there any other heating units vented through this chimney?
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.
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?
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?
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?
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?
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?
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?
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)
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)
7. What is the size of thimble or roof joist shield used? (Inches)
Do these distances comply with the stove manufacturer's standards?
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?
What type of fuel is used in this stove?
Wood
Coal
Is there a fire extinguisher in the room with the stove?
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?
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?
Do you have a smoke alarm in operation in your home?
Yes
No
Please upload a picture of your stove.
Please upload a picture of your stove.
Max. file size: 128 MB.
Please enter any additional remarks related to your wood burning stove below.
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.
I agree
AJG (Ericson) Service
860-868-7361
www.ericsoninsurance.com
GGB.WashingtonDepot.Service@ajg.com
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