SOLID FUEL HEATING QUESTIONNAIRE PLEASE ATTACH PHOTOGRAPH
Policy No:
Insured:
Agent/Broker:
Address of premises where unit is installed, Principal residence or
location of unit within the dwelling.
HEATING UNIT
Type (a) ‫ ڤ‬Fireplace (with doors)
(e) ‫ ڤ‬Factory manufactured oil/solid fuel combination unit
(b) ‫ ڤ‬Pot belly, box, franklin or acorn stove
(f) ‫ ڤ‬Oil furnace with add.on solid fuel burning unit
(loose fitting doors or no doors)
(c) ‫ ڤ‬Airtight" stove
(g) ‫ ڤ‬Other, specify
(d) ‫ ڤ‬Airtight" insert in
‫ ڤ‬Solid masonry fireplace
"Airtight - tight fitting doors and seams
‫ ڤ‬Zero clearance fireplace
Fuel
‫ ڤ‬Wood only
‫ ڤ‬Wood and oil
‫ ڤ‬Other. specify
Quantity of wood burned per year
Stored where and how
Make
Labelled
Model
Age
‫ ڤ‬Canadian Standards Association
‫ ڤ‬Underwriters' Laboratories of Canada
‫ ڤ‬Warnock.Hersey Professional Service Ltd
‫ ڤ‬None or other, specify
How often is the heating unit used during the heating season?
Chimney
Type
hours per day
days per week
‫ ڤ‬Masonry - ‫ ڤ‬Built from ground ‫ ڤ‬Bracket Chimney lining - ‫ ڤ‬Flue tile ‫ ڤ‬None or other, specify
‫ ڤ‬Factory built double walled metal chimney - manufacturer
Labelled
‫ ڤ‬Canadian Standards Association
‫ ڤ‬Underwriters' Laboratories of Canada
‫ ڤ‬Warnock.Hersey Professional Service Ltd.
‫ ڤ‬None or other specify
‫ ڤ‬Other type of chimney, specify
‫ ڤ‬Unknown
‫ ڤ‬Same as heating unit or
Was the chimney designed for the type of fuel specified above?
Does unit share a chimney flue with any other heating unit ‫ ڤ‬no
Chimney is installed
‫ ڤ‬inside building
‫ ڤ‬outside building
How often is the chimney cleaned
‫ ڤ‬yes or identify fuel for which designed
‫ ڤ‬yes, describe other unit overleaf and indicate which pipe enters
Chimney above the other.
Date of last cleaning (year. month)
Installation: How many 90° bends are in the pipe?
Was the heating unit installed by a heating contractor ‫ ڤ‬unknown ‫ ڤ‬no ‫ ڤ‬yes, name of firm
Was the chimney installed by a heating or masonry contractor ‫ ڤ‬unknown ‫ ڤ‬no ‫ ڤ‬yes, name of firm
Does the stovepipe pass through a concealed space or any wall, partition, floor or ceiling of combustible construction ‫ ڤ‬yes ‫ ڤ‬no
Is protective shielding used around heating unit-if so, describe (material used, clearances, etc" )
Diagram (Please complete the following for hearing types (b), (c), and (g). If your unit does not fit diagram please attach your own.)
1. Construction of back wall
2. Shortest distance from unit to back wall
‫ ڤ‬in ‫ ڤ‬cm
3. Is there a thimble where the pipe passes through wall? ‫ ڤ‬yes ‫ ڤ‬no
Total length or stovepipe ‫ ڤ‬in ‫ ڤ‬cm
4. Shortest distance from stovepipe to ceiling ‫ ڤ‬in ‫ ڤ‬cm
5. Is there a noncombustible pad? ‫ ڤ‬yes ‫ ڤ‬no
6. Construction of floor
7. Distance from unit to floor
‫ ڤ‬in ‫ ڤ‬cm
8. Distance from side of unit to end of pad ‫ ڤ‬in ‫ ڤ‬cm
9. Distance from front or unit to end of pad ‫ ڤ‬in ‫ ڤ‬cm
10. Construction or nearest side wall
11, Shortest distance from unit to nearest side wall ‫ ڤ‬in ‫ ڤ‬cm
12. Shortest distance from unit to 'furniture, fuel or other combustible
material ‫ ڤ‬in ‫ ڤ‬cm
Has the installation including chimney been inspected and approved by a fire department or building code inspector.
Completed
Date