UTX-QUES-304 (12-02)
WOOD/COAL BURNING FACILITY
QUESTIONNAIRE
Policy No.: ________________________________________________
Insured:___________________________________________________
Agent: ____________________________________________________
Location of Risk: __________________________________________
___________________________________________________________
REQUIREMENTS
1. A photo of the wood/coal burning facility must be submitted with this Questionnaire.
2. Questionnaire and photo must be submitted with application for insurance.
3. Questionnaire must be inspected and signed by a licensed contractor or member of local fire department when facility
is NOT factory installed or commercially installed by appliance distributor or licensed expert.
STOVE INFORMATION
TYPE Radiant Circulating Franklin Other (specify):
MAKE/NAME By: U.L. Approved?................. Yes No
USE Primary Heat Auxiliary Heat Cooking Other (specify):
INSTALLED By: Date:
FLOOR PROTECTION Asbestos Millboard Covered with Metal Metal Stone/Brick Other (specify below)
WALL PROTECTION Asbestos Millboard Covered with Metal Metal Asb. Millbrd Other (specify below)
CHIMNEY TYPE: Factory Masonry Other (describe):
How often checked for creosote build-up?
Date Last Cleaned: By Whom?
CHIMNEY
&
STOVE PIPES
Does vent pass through a combustible partition?........................................................ Yes No
If yes, is protection thimble or sleeve used?................................................................ Yes No
Does pipe vent pass directly through the roof? ........................................................... Yes No
Are any other heating units vented to chimney?.......................................................... Yes No
(describe below)
Is stove vent system equipped with heat reclaiming unit or flue radiator? .................. Yes No
CLEARANCES
1. Side of unit to nearest wall ..................................... _________ inches.
2. Rear of unit to wall..................................................
_________ inches.
3. Top of stovepipe to ceiling...................................... _________ inches.
4. Bottom of unit to floor..............................................
_________ inches.
5. Front of unit to front edge of floor protection ..........
_________ inches.
6. Size of stovepipe used ........................................... _________ inches.
7. Size of thimble or roof joist shield...........................
_________ inches.
Do these distances comply with the manufacturer’s
standards?........................................................................... Yes No
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MISCELLANEOUS
FUEL Wood Coal Other (specify):
PREVENTION Fire Extinguisher in Room?............... Yes No Smoke Alarm? .................... Yes No
ADDITIONAL
REMARKS
Inspector Signature: _________________________________________________________ Date Inspected:________________________
PHOTO MUST BE ATTACHED
