Insurance Wood Stove Questionnaire

INSURANCE WOOD STOVE QUESTIONNAIRE

Applicant / Insured Information

Applicant Name:

Date of Birth:    Home Phone:

Policy Details

Policy Type:    Coverage Limit:

Deductible:    Premium:

Policy Period From:    To:

Wood Stove Details

Stove Type: Freestanding Insert Fireplace Stove Pellet Stove

Date of Installation:    Installed By: Licensed Contractor Homeowner (self) Manufacturer Representative

Was a local building permit obtained for the installation? Yes No

Chimney / Venting

Chimney Height (above stove):    Flue Size:

Hearth & Floor Protection

Is the wood stove installed on a noncombustible hearth that complies with the manufacturer's clearance requirements? Yes No

Fuel, Usage & Practices

Primary Fuel Type: Seasoned hardwood Softwood Pellets Manufactured logs

Is the stove routinely left burning unattended overnight? Yes No

Maintenance & Safety

Last Chimney Sweep or Inspection Date:

Smoke Detectors Installed? Yes No    Carbon Monoxide Alarms Installed? Yes No

Previous Losses / Alterations

Has this stove or chimney been involved in a prior loss or claim? Yes No

Have any modifications been made to the stove, chimney, or venting since original installation? Yes No

Documentation & Photographs

Documentation checklist (mark all provided): Photos of stove and installation Installation receipt Manufacturer's manual Photo of UL/ETL label Chimney inspection report Permit copy (if applicable)

Coverage Acknowledgements & Exclusions

The Insured acknowledges that coverage for damage arising from the wood stove is subject to policy terms, conditions and exclusions. Common exclusions include, but are not limited to: failure to maintain the stove or chimney; use of inappropriate fuels or accelerants; installation not in accordance with manufacturer instructions or local codes; alterations to stove or chimney without licensed contractor work; storage of combustible materials too near stove; and unattended misuse. Mark to acknowledge receipt and understanding: I acknowledge and understand these exclusions and conditions.

Beneficiary Designation

Beneficiary Name:

Declaration / Certification

I certify that the information provided in this questionnaire is true, complete and accurate to the best of my knowledge. I understand that any material misrepresentation or omission may result in denial of coverage or rescission of the policy. I authorize the insurer and its representatives to inspect the wood stove, chimney and related installations at reasonable times to verify the statements herein. I agree to maintain the stove and chimney in a safe manner consistent with manufacturer's instructions and applicable codes. This questionnaire does not change the terms, conditions or limits of the insurance policy; coverage is governed by the policy language.

I further understand that the insurer may rely on this information when underwriting and rating the policy and that submission of false or misleading information may be considered fraud under applicable law.

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