<p>Wood Questionnaire for Furnaces</p><p>Photo of Appliance is required</p><p>Insured Name: Policy Number:</p><p>Address:</p><p>Brokers Name:</p><p>1. Type of Appliance: Wood Furnace Add on unit Combination Solid Fuel Other 2. Make: Age: Installed by: 3. Labeled: CSA ULC Warnock-Hersey No Label 4. Distance from side of unit to combustible material in cm 5. Distance from rear of unit to combustible material in cm 6. Hot Water Hot Air If Hot Air: Ductwork and Plenum Clearances Required Actual Plenum Hot Air Supply Cold Air Return 7. Type of Flue Pipe: Black Stainless Steel Galvanized 8. Flue pipe clearance to combustibles? in cm 9. Heat shield installed? Yes No If no, explain: 10. Length of stovepipe from furnace to chimney: in cm Chimney</p><p>12. Masonry – lined Unlined Flue Tiled Factory built 13. Inside Outside 14. Age: Approved by: 15: How often is chimney cleaned? yearly annually 16. Is chimney shared with other heating appliance: Yes No If yes, a) what other appliance is vented into chimney? b) is other appliance vented above furnace? Yes No 17. Does flue pipe pass through combustible wall? Yes No 18. Is there an approved thimble? Yes No 19. How many cords of wood are burned annually? 20. Where is the wood stored? 21. Do you have a backup source of heat? Yes No If yes, explain:</p><p>Completed by Date</p><p>2419 (03/09) 2419 (03/09)</p>