LPI Solid Fuel Heating Unit Questionnaire Name: Address: Is your home insured? Yes No If yes, Policy No: Broker: Do you use the unit as: Primary Heat Source Ordinary Stove Auxillary Heating Source Airtight Stove Cooking Stove Is the appliance: CSA ULC Warnock Hersey Manufacturer: Model: Age: Please view diagram at the bottom of this page for descriptive terms. Is there at least 18 inches between the unit and any shielded combustible material? Yes No Is there at least 18 inches from the loading side-door and 8 inches on the other three sides? Yes No The floor construction supporting the stove is: Concrete Only Frame Only Frame Covered with a Non-Combustible Material Distance between stove and combustibles (furniture, drapes, carpet Etc.): FLUE PIPE  Is there at least 18 inches between the pipe and any combustible material? Yes No If the pipe goes through the wall or ceiling, is there a metal thimble of at least 18 inches in diameter? Yes No How often are the pipes cleaned? CHIMNEY  Chimney is: Factory Built CSA ULC Warnock Hersey Other (Describe) If other, please describe: Who installed it? If chimney is metal, is there at least 2 inches clearance between the chimney and any combustible material? Yes No Does the appliance share a chimney with any other heating appliance? Yes No Is the chimney professionally cleaned annually? Yes No If no, how often? FIREPLACE  Fireplace is: Masonry Freestand Insert (0 Clearance) Freestanding Metal Fireplace Prefabricated Fireplace Insert (Other) Installation date: Make: Model: INSTALLATION  Who was unit installed by? Has it been inspected and approved by: Fire Department Official Building Inspector Miscellaneous Information Do you use a metal container for ash removal? Yes No Approx. Hours per Day of Use: Number of Fire Extinguishers: Distance of Fire Extinguishers: Submit Form Should be Empty:   Disclaimer: This Online form is for estimates only and does not constitute a binding agreement. One of our qualified representatives will contact you for additional information that may be required and to provide you with a quote.