Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 73 (2009/07)
Solid Fuel Questionnaire -
Supplement to Residential Section
ACORD 73, Solid Fuel Questionnaire, is used with all personal
property applications, when the property contains a heating appliance that uses solid fuel
such as coal or wood, and specific information about such heating appliances is required
by the company
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION SECTION Loc #
Enter number: The producer assigned number of the location. As used here, the location
number of the risk's location as it appears on ACORD 88, Personal Insurance Application,
Applicant Information Section.
IDENTIFICATION SECTION Item #
Enter number: The producer assigned number for the heating unit. As used here, the item
number of the risk as it appears on ACORD 88, Personal Insurance Application, Applicant
Information Section.
IDENTIFICATION SECTION Date
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION Agency
Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION Policy Number
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If
required for self-insurance, the self-insured license or contract number.
IDENTIFICATION SECTION Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence.
IDENTIFICATION SECTION Carrier
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy.
Use the actual name of the company within the group to which the policy has been issued.
This is not the insurer's group name or trade name.
IDENTIFICATION
NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION Named Insured(s)
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
SOLID FUEL DEVICE
Manufacturer
Enter text: The name of the manufacturer of the heating unit.
SOLID FUEL DEVICE
Brand Name
Enter text: The brand name of the item. This is used when a manufacturer produced the
item that is sold under a different name.
SOLID FUEL DEVICE
Model Number
Enter text: The manufacturer's model name or number for the heating unit.
SOLID FUEL DEVICE
Fuel Type: Coal
Check the box (if applicable): Indicates the fuel type of the heating unit is coal.
SOLID FUEL DEVICE
Fuel Type: Corn
Check the box (if applicable): Indicates the fuel type of the heating unit is corn.
SOLID FUEL DEVICE
Fuel Type: Pellet
Check the box (if applicable): Indicates the fuel type of the heating unit is pellet.
SOLID FUEL DEVICE
Fuel Type: Wood
Check the box (if applicable): Indicates the fuel type of the heating unit is wood.
ACORD 73 (2009/07) rev. 07-31-2009
1 of 11
Section Name
Field Name
Field and/or Section Description
SOLID FUEL DEVICE
Fuel Type: Other
Check the box (if applicable): Indicates the fuel type of the heating unit is other than those
listed.
SOLID FUEL DEVICE
Fuel Type: Describe
Enter text: The description of the type of fuel used by the heating unit.
SOLID FUEL DEVICE
Stove Type: Radiant
Check the box (if applicable): Indicates the stove type is radiant.
SOLID FUEL DEVICE
Stove Type: Circulating
Check the box (if applicable): Indicates the stove type is circulating.
SOLID FUEL DEVICE
Testing Laboratory Label:
Underwriters Laboratory
Check the box (if applicable): Indicates the entity that certified the item for use or sale was
Underwriters Laboratory (UL).
SOLID FUEL DEVICE
Testing Laboratory Label:
Underwriters Laboratory of
Canada
Check the box (if applicable): Indicates the entity that certified the item for use or sale was
Underwriters Laboratory of Canada (ULC).
SOLID FUEL DEVICE
Testing Laboratory Label:
Canadian Standards Association
Check the box (if applicable): Indicates the entity that certified the item for use or sale was
Canadian Standards Association (CSA).
SOLID FUEL DEVICE
Testing Laboratory Label: Other
Testing Laboratory Label
Check the box (if applicable): Indicates the entity that certified the item for use or sale was
other than those listed.
SOLID FUEL DEVICE
Testing Laboratory Label:
Describe
Enter text: The description of the entity that certified the item for use or sale.
SOLID FUEL DEVICE
Unit Type: Free Standing
Check the box (if applicable): Indicates the type of heating unit is a free standing unit.
SOLID FUEL DEVICE
Unit Type: Fireplace Insert
Check the box (if applicable): Indicates the type of heating unit is a fireplace insert.
SOLID FUEL DEVICE
Unit Type: Barrel Type
Check the box (if applicable): Indicates the type of heating unit is a barrel type unit.
SOLID FUEL DEVICE
Unit Type: Forced Air Furnace
Check the box (if applicable): Indicates the type of heating unit is a forced air furnace.
SOLID FUEL DEVICE
Unit Type: Add On
Check the box (if applicable): Indicates the type of heating unit is an add on.
SOLID FUEL DEVICE
Unit Type: Pellet
Check the box (if applicable): Indicates the type of heating unit is a pellet unit.
SOLID FUEL DEVICE
Unit Type: Central Hot Water
Check the box (if applicable): Indicates the type of heating unit is a central hot water unit.
SOLID FUEL DEVICE
Unit Type: Homemade
Check the box (if applicable): Indicates the type of heating unit is homemade.
SOLID FUEL DEVICE
Unit Type: Fireplace
Check the box (if applicable): Indicates the type of heating unit is a fireplace.
SOLID FUEL DEVICE
Unit Type: Unit Other
Check the box (if applicable): Indicates the type of heating unit is other than those listed.
SOLID FUEL DEVICE
Unit Type: Describe
Enter text: The description of the type of heating unit.
SOLID FUEL DEVICE
Construction: Cast Iron
Check the box (if applicable): Indicates the heating unit is constructed of cast iron.
SOLID FUEL DEVICE
Construction: Plate Steel
Check the box (if applicable): Indicates the heating unit is constructed of plate steel.
SOLID FUEL DEVICE
Construction: Sheet Metal
Check the box (if applicable): Indicates the heating unit is constructed of sheet metal.
ACORD 73 (2009/07) rev. 07-31-2009
2 of 11
Section Name
Field Name
Field and/or Section Description
SOLID FUEL DEVICE
Construction: Other
Check the box (if applicable): Indicates the heating unit is constructed of a material other
than those listed.
SOLID FUEL DEVICE
Construction: Other Description
Enter text: The description of the construction material of the heating unit.
SOLID FUEL DEVICE
Location of Device: Basement
Check the box (if applicable): Indicates the heating unit is located in the basement.
SOLID FUEL DEVICE
Location of Device: Attached
Garage
Check the box (if applicable): Indicates the heating unit is located in the attached garage.
SOLID FUEL DEVICE
Location of Device: Main Living
Area
Check the box (if applicable): Indicates the heating unit is located in the main living area.
SOLID FUEL DEVICE
Location of Device: Other
Check the box (if applicable): Indicates the heating unit is located other than those
locations listed.
SOLID FUEL DEVICE
Location of Device: Describe
Enter text: The description of the placement of the heating unit.
SOLID FUEL DEVICE
Installation Inspected By Fire
Department
Check the box (if applicable): Indicates the installation was inspected by the fire
department.
SOLID FUEL DEVICE
Installation Inspected By Local
Building Inspector
Check the box (if applicable): Indicates the installation was inspected by a local building
inspector.
SOLID FUEL DEVICE
Installation Not Inspected
Check the box (if applicable): Indicates the installation was not inspected.
SOLID FUEL DEVICE
Installation Inspected Other
Check the box (if applicable): Indicates the installation was inspected by other than those
listed.
SOLID FUEL DEVICE
Installation Inspected By Other:
Describe
Enter text: The description of the party that inspected the installation of the heating unit.
SOLID FUEL DEVICE
Heating Use Total (Only Heat
Source)
Check the box (if applicable): Indicates the heating unit is the only heat source.
SOLID FUEL DEVICE
Heating Use Primary
Check the box (if applicable): Indicates the heating unit is the main heat source.
SOLID FUEL DEVICE
Heating Use Supplemental
Check the box (if applicable): Indicates the heating unit is a supplementary heat source.
SOLID FUEL DEVICE
Heating Use Occasional
Check the box (if applicable): Indicates the heating unit is used occasionally.
SOLID FUEL DEVICE
Other Heating Source Used: Gas
Check the box (if applicable): Indicates the other heat source is fueled by gas.
SOLID FUEL DEVICE
Other Heating Source Used: Oil
Check the box (if applicable): Indicates the other heat source is fueled by oil.
SOLID FUEL DEVICE
Other Heating Source Used:
Electric
Check the box (if applicable): Indicates the other heat source is fueled by electricity
SOLID FUEL DEVICE
Other Heating Source Used: Other
Check the box (if applicable): Indicates the other heat source is fueled by other than those
listed.
SOLID FUEL DEVICE
Other Heating Source Used:
Describe
Enter text: The description of the fuel used by the other heat source.
ACORD 73 (2009/07) rev. 07-31-2009
3 of 11
Section Name
Field Name
Field and/or Section Description
SOLID FUEL DEVICE
Other Heating Source Used: None
Check the box (if applicable): Indicates there is no other heat source used.
SOLID FUEL DEVICE
Year Installed
Enter year: The year the heating unit was installed.
SOLID FUEL DEVICE
Installation Done By: Professional
Check the box (if applicable): Indicates the heating unit was installed by a professional.
SOLID FUEL DEVICE
Installation Done By: Non
Professional
Check the box (if applicable): Indicates the heating unit was installed by a non-
professional.
SOLID FUEL DEVICE
Installation Done By: Unknown
Check the box (if applicable): Indicates the heating unit was installed by an unknown
party.
SOLID FUEL DEVICE
Installer Name
Enter text: The full name of the installer of the heating unit.
SOLID FUEL DEVICE
1. Is the device free from large
cracks and broken parts?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is the device free from large cracks and/or broken parts?.
CHIMNEY
Construction: Masonry Without
Liner
Check the box (if applicable): Indicates the chimney is constructed of masonry without a
liner.
CHIMNEY
Construction: Masonry With Liner
Check the box (if applicable): Indicates the chimney is constructed of masonry with a liner.
CHIMNEY
Construction: Metal Triple Wall
Check the box (if applicable): Indicates the chimney is constructed of metal, triple wall
(class A and UL listed).
CHIMNEY
Construction: Metal Double Wall
Check the box (if applicable): Indicates the chimney is constructed of metal, double wall
insulated (class A and UL listed).
CHIMNEY
Construction: Metal Single Wall
Check the box (if applicable): Indicates the chimney is constructed of metal, single wall
(class A and UL listed).
CHIMNEY
Construction: Other
Check the box (if applicable): Indicates the chimney is constructed of other than those
materials listed.
CHIMNEY
Construction: Other, Describe
Enter text: The description of the material used to construct the chimney.
CHIMNEY
1. Is the stove vented into the
same chimney flue (double
vented) with a heating device
using a different type of fuel?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is the stove vented into the same chimney flue (double vented) with a heating
device using a different fuel?.
CHIMNEY
Fuel Type Gas
Check the box (if applicable): Indicates the heating unit that shares the flue with the unit
being described is fuelled by gas.
CHIMNEY
Above Chimney
Check the box (if applicable): Indicates a vent for another heat source is located above the
vent for the device being described.
CHIMNEY
Same Level as Chimney
Check the box (if applicable): Indicates a vent for another heat source is located on the
same level as the vent for the device being described.
ACORD 73 (2009/07) rev. 07-31-2009
4 of 11
Section Name
Field Name
Field and/or Section Description
CHIMNEY
Below Chimney
Check the box (if applicable): Indicates a vent for another heat source is located below the
vent for the device being described.
CHIMNEY
Fuel Type Oil
Check the box (if applicable): Indicates the heating unit that shares the flue with the unit
being described is fuelled by oil.
CHIMNEY
Above Chimney
Check the box (if applicable): Indicates a vent for another heat source is located above the
vent for the device being described.
CHIMNEY
Same Level as Chimney
Check the box (if applicable): Indicates a vent for another heat source is located on the
same level as the vent for the device being described.
CHIMNEY
Below Chimney
Check the box (if applicable): Indicates a vent for another heat source is located below the
vent for the device being described.
CHIMNEY
Fuel Type Other Wood
Check the box (if applicable): Indicates the heating unit that shares the flue with the unit
being described is fuelled by wood.
CHIMNEY
Above Chimney
Check the box (if applicable): Indicates a vent for another heat source is located above the
vent for the device being described.
CHIMNEY
Same Level as Chimney
Check the box (if applicable): Indicates a vent for another heat source is located on the
same level as the vent for the device being described.
CHIMNEY
Below Chimney
Check the box (if applicable): Indicates a vent for another heat source is located below the
vent for the device being described.
CHIMNEY
Fuel Type Other
Check the box (if applicable): Indicates the heating unit that shares the flue with the unit
being described is fuelled by other than those listed.
CHIMNEY
Describe Other Fuel Type
Enter text: The description of the fuel used by the heating unit that shares the flue with the
unit being described.
CHIMNEY
Above Chimney
Check the box (if applicable): Indicates a vent for another heat source is located above the
vent for the device being described.
CHIMNEY
Same Level as Chimney
Check the box (if applicable): Indicates a vent for another heat source is located on the
same level as the vent for the device being described.
CHIMNEY
Below Chimney
Check the box (if applicable): Indicates a vent for another heat source is located below the
vent for the device being described.
CHIMNEY
2. If construction is masonry,
does tile flue lining extend from
below the stove pipe entry point to
the top of the chimney?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, If the construction is masonry, does tile flue lining extend from below the
stovepipe entry point to the top of the chimney?.
CHIMNEY
3. If the construction is masonry,
is the chimney built from the
ground up?
Enter Y for a Yes response. Input N for No response. Indicates if the masonry chimney
was built from the ground up.
ACORD 73 (2009/07) rev. 07-31-2009
5 of 11
Section Name
Field Name
Field and/or Section Description
CHIMNEY
4. Was the chimney installed after
the house was built and for this
solid fuel device?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Was the chimney installed after the house was built and for this solid fuel
heating device?.
CHIMNEY
5. Is the chimney covered with
or hidden behind a combustible
wall?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is the chimney covered with or hidden behind a combustible wall?.
STOVE PIPE
Stove Pipe Type: Single Wall Metal
Check the box (if applicable): Indicates the stove pipe is single wall metal.
STOVE PIPE
Stove Pipe Type: Double Wall
Metal
Check the box (if applicable): Indicates the stove pipe is laboratory listed double wall or
insulated.
STOVE PIPE
Vent Style: Catalytic Converter
Check the box (if applicable): Indicates the style of the chimney pipe vent is catalytic
converter.
STOVE PIPE
Vent Style: Circulating Fan
Check the box (if applicable): Indicates the style of the chimney pipe vent is circulating
fan.
STOVE PIPE
Vent Style: Heat Extractor
Check the box (if applicable): Indicates the style of the chimney pipe vent is heat extractor.
STOVE PIPE
Vent Style: Heat Reclaimer
Check the box (if applicable): Indicates the style of the chimney pipe vent is heat
reclaimer.
STOVE PIPE
Vent Style: Waste Heat Collector
Circulator
Check the box (if applicable): Indicates the style of the chimney pipe vent is waste heat
collector/circulator.
STOVE PIPE
Vent Style: Other Vent Style
Check the box (if applicable): Indicates the style of the chimney pipe vent is other than
those listed.
STOVE PIPE
Vent Style: Other, Describe.
Enter text: The description of the chimney pipe vent style.
STOVE PIPE
Diameter of the Stove Pipe
Enter number: The diameter, in inches, of the heat pipe connected to the heat source.
STOVE PIPE
1. Does the pipe fit snug into the
chimney opening?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Does the smoke pipe fit snug into the chimney opening?.
STOVE PIPE
2. Are stove pipe connections
securely fastened to each other
with screws at each connection?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Are stove pipe connections securely fastened to each other with screws at each
connection?.
STOVE PIPE
3. Does the stove pipe pass
through any interior combustible
wall, ceiling, closet or concealed
area?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Does the stove pipe pass through any interior combustible wall, ceiling, closet,
or concealed area?.
ACORD 73 (2009/07) rev. 07-31-2009
6 of 11
Section Name
Field Name
Field and/or Section Description
STOVE PIPE
Smoke Pipe Passes Through
Ventilated Thimble
Check the box (if applicable): Indicates that a stove pipe that passes through an interior
combustible was, ceiling, closet or concealed area passes through a thimble.
STOVE PIPE
Ventilated Thimble Diameter in
Inches
Enter number: The diameter, in inches, of the thimble the stove pipe passes through.
STOVE PIPE
Smoke Pipe No Thimble
Check the box (if applicable): Indicates that a stove pipe that passes through an interior
combustible was, ceiling, closet or concealed area does not pass through a thimble.
STOVE PIPE
Distance from Pipe to Outer Edges
of Opening in Inches
Enter number: The distance, in inches, from the stove pipe to the outer edges of the
openings.
STOVE PIPE
Remarks
Enter text: The remarks associated with the heating unit. Attach ACORD 101, Additional
Remarks Schedule, if more space is required.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION SECTION Loc #
Enter number: The producer assigned number of the location.
IDENTIFICATION SECTION Item #
Enter number: The producer assigned number for the heating unit.
UNIT CLEARANCES
1. Does the stove installation and
use conform to all of its
manufacturer's specifications and
local fire codes?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Does the stove installation and use conform to all of its manufacturers
specifications and local fire codes?.
UNIT CLEARANCES
Distance From Unit To Rear Wall
Inches
Enter number: The distance, in inches, from the heating unit to the rear wall.
UNIT CLEARANCES
Distance From Unit To Left Wall
Inches
Enter number: The distance, in inches, from the heating unit to the left wall.
UNIT CLEARANCES
Distance From Unit To Right Wall
Inches
Enter number: The distance, in inches, from the heating unit to the right wall.
UNIT CLEARANCES
Distance From Unit To Ceiling
Inches
Enter number: The distance, in inches, from the heating unit to the ceiling.
UNIT CLEARANCES
Distance From Bottom Of Unit To
Floor Inches
Enter number: The distance, in inches, from the bottom of the heating unit to the floor.
UNIT CLEARANCES
Distance From Front Of Unit To
Front Edge Of Floor Protection
Inches
Enter number: The distance, in inches, from the front of the heating unit to the front ledge
of the floor protection.
ACORD 73 (2009/07) rev. 07-31-2009
7 of 11
Section Name
Field Name
Field and/or Section Description
UNIT CLEARANCES
Distance To Other Combustibles
From Front Of Device Inches
Enter number: The distance, in inches, to furniture, drapes, wood storage or other
combustibles from the front of heating unit.
UNIT CLEARANCES
Shortest Distance From Stove
Pipe To Any Wall Inches
Enter number: The distance, in inches, from the stove pipe to the closest wall.
UNIT CLEARANCES
Distance From Top Of Pipe To
Ceiling Inches
Enter number: The distance, in inches, from the top of the stove pipe to the ceiling.
PROTECTIVE MATERIAL
Protective Material Used for Walls:
None
Check the box (if applicable): Indicates there is no protective material on the walls.
PROTECTIVE MATERIAL
Protective Material Used for Walls:
Brick
Check the box (if applicable): Indicates the protective material on the walls is brick.
PROTECTIVE MATERIAL
Protective Material Used for Walls:
Ceramic Tile
Check the box (if applicable): Indicates the protective material on the walls is ceramic tile.
PROTECTIVE MATERIAL
Protective Material Used for Walls:
Concrete
Check the box (if applicable): Indicates the protective material on the walls is concrete.
PROTECTIVE MATERIAL
Protective Material Used for Walls:
Fire Board
Check the box (if applicable): Indicates the protective material on the walls is fire board.
PROTECTIVE MATERIAL
Protective Material Used for Walls:
Sheet Metal
Check the box (if applicable): Indicates the protective material on the walls is sheet metal.
PROTECTIVE MATERIAL
Protective Material Used for Walls:
Stainless Steel
Check the box (if applicable): Indicates the protective material on the walls is stainless
steel.
PROTECTIVE MATERIAL
Protective Material Used for Walls:
Stone
Check the box (if applicable): Indicates the protective material on the walls is stone.
PROTECTIVE MATERIAL
Protective Material Used for Walls:
Other Material Type
Enter text: The description of the material protecting the walls.
PROTECTIVE MATERIAL
Protective Material Used for Walls:
Air Space Inches
Enter number: The number of inches between the protective material and the walls.
PROTECTIVE MATERIAL
Protective Material Used for
Floors: None
Check the box (if applicable): Indicates there is no protective material on the floor.
PROTECTIVE MATERIAL
Protective Material Used for
Floors: Brick
Check the box (if applicable): Indicates the protective material on the floor is brick.
PROTECTIVE MATERIAL
Protective Material Used for
Floors: Ceramic Tile
Check the box (if applicable): Indicates the protective material on the floor is ceramic tile.
PROTECTIVE MATERIAL
Protective Material Used for
Floors: Concrete
Check the box (if applicable): Indicates the protective material on the floor is concrete.
PROTECTIVE MATERIAL
Protective Material Used for
Floors: Fire Board
Check the box (if applicable): Indicates the protective material on the floor is fire board.
ACORD 73 (2009/07) rev. 07-31-2009
8 of 11
Section Name
Field Name
Field and/or Section Description
PROTECTIVE MATERIAL
Protective Material Used for
Floors: Sheet Metal
Check the box (if applicable): Indicates the protective material on the floor is sheet metal.
PROTECTIVE MATERIAL
Protective Material Used for
Floors: Stainless Steel
Check the box (if applicable): Indicates the protective material on the floor is stainless
steel.
PROTECTIVE MATERIAL
Protective Material Used for
Floors: Stone
Check the box (if applicable): Indicates the protective material on the floor is stone.
PROTECTIVE MATERIAL
Protective Material Used for
Floors: Other Material Type
Enter text: The description of the material protecting the floor.
PROTECTIVE MATERIAL
Protective Material Used for
Floors: Air Space Inches
Enter number: The number of inches between the protective material and the floor.
PROTECTIVE MATERIAL
Protective Material Used for
Ceiling: None
Check the box (if applicable): Indicates there is no protective material on the ceiling.
PROTECTIVE MATERIAL
Protective Material Used for
Ceiling: Brick
Check the box (if applicable): Indicates the protective material on the ceiling is brick.
PROTECTIVE MATERIAL
Protective Material Used for
Ceiling: Ceramic Tile
Check the box (if applicable): Indicates the protective material on the ceiling is ceramic
tile.
PROTECTIVE MATERIAL
Protective Material Used for
Ceiling: Concrete
Check the box (if applicable): Indicates the protective material on the ceiling is concrete.
PROTECTIVE MATERIAL
Protective Material Used for
Ceiling: Fire Board
Check the box (if applicable): Indicates the protective material on the ceiling is fire board.
PROTECTIVE MATERIAL
Protective Material Used for
Ceiling: Sheet Metal
Check the box (if applicable): Indicates the protective material on the ceiling is sheet
metal.
PROTECTIVE MATERIAL
Protective Material Used for
Ceiling: Stainless Steel
Check the box (if applicable): Indicates the protective material on the ceiling is stainless
steel.
PROTECTIVE MATERIAL
Protective Material Used for
Ceiling: Stone
Check the box (if applicable): Indicates the protective material on the ceiling is stone.
PROTECTIVE MATERIAL
Protective Material Used for
Ceiling: Other Material Type
Enter text: The description of the material protecting the ceiling.
PROTECTIVE MATERIAL
Protective Material Used for
Ceiling: Air Space Inches
Enter number: The number of inches between the protective material and the ceiling.
FIRE PROTECTION
1. Is there a fire extinguisher in
operating condition in the
dwelling?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is there a fire extinguisher in operating condition in the dwelling?.
FIRE PROTECTION
2. Is there a smoke detector in the
dwelling?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is there a smoke detector in the dwelling?.
ACORD 73 (2009/07) rev. 07-31-2009
9 of 11
Section Name
Field Name
Field and/or Section Description
FIRE PROTECTION
3. Is there a heat sensor in the
dwelling?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is there a heat sensor in the dwelling?.
FIRE PROTECTION
4. Is there a carbon monoxide
(CO) detector in the dwelling?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is there a carbon monoxide (CO) detector in the dwelling?.
CLEANING
Frequency the Stove, Chimney
and Stove/Smoke Pipe are
Cleaned and Inspected: Annually
Check the box (if applicable): Indicates the chimney is cleaned annually.
CLEANING
Frequency the Stove, Chimney
and Stove/Smoke Pipe are
Cleaned and Inspected: Semi
Annually
Check the box (if applicable): Indicates the chimney is cleaned semi-annually.
CLEANING
Frequency the Stove, Chimney
and Stove/Smoke Pipe are
Cleaned and Inspected: Quarterly
Check the box (if applicable): Indicates the chimney is cleaned quarterly.
CLEANING
Frequency the Stove, Chimney
and Stove/Smoke Pipe are
Cleaned and Inspected: Other
Check the box (if applicable): Indicates the chimney is cleaned at a frequency other than
those listed.
CLEANING
Frequency the Stove, Chimney
and Stove/Smoke Pipe are
Cleaned and Inspected: Describe.
Enter text: The description of the frequency the chimney is cleaned.
CLEANING
Cleaned and Inspected By:
Enter text: The full name of the party that cleaned and inspected the chimney.
CLEANING
Is This Person a Certified Chimney
Sweep?
Enter Y for a Yes response. Input N for No response. Indicates the person cleaning
and inspecting the chimney is a certified chimney sweep.
CLEANING
Date of Last Cleaning
Enter date: The last date the chimney was cleaned.
CLEANING
Describe the Container Used to
Store Ashes
Enter text: The description of the container used to store ashes.
CLEANING
Describe Where the Ashes are
Stored
Enter text: The description of the location where ashes are stored.
ATTACHMENTS
Attachments - Photo of the Interior
Check the box (if applicable): Indicates a photograph of the interior with stove installed,
including floor protection is attached.
ATTACHMENTS
Attachments - Photo Exterior With
Chimney
Check the box (if applicable): Indicates a photograph of the exterior with the chimney.
ACORD 73 (2009/07) rev. 07-31-2009
10 of 11
Section Name
Field Name
Field and/or Section Description
ATTACHMENTS
Attachment - Other
Check the box (if applicable): Indicates there is an attachment other than those listed.
ATTACHMENTS
Attachment - Other Describe
Enter text: The description of the attachment.
REMARKS
Remarks
Enter text: The remarks associated with the heating unit. Attach ACORD 101, Additional
Remarks Schedule, if more space is required.
SIGNATURE SECTIONS
Signature of Person Completing
This Form
Sign here: Accommodates the signature of the person completing the form.
SIGNATURE SECTIONS
Signed By Applicant
Check the box (if applicable): Indicates the applicant completed the form.
SIGNATURE SECTIONS
Signed By Producer
Check the box (if applicable): Indicates the producer completed the form.
SIGNATURE SECTIONS
Signed By Other
Check the box (if applicable): Indicates the form was completed by someone other than
those listed
SIGNATURE SECTIONS
Describe
Enter text: The description of the party completing the form.
SIGNATURE SECTIONS
Date
Enter date: The date the form was signed.
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
ACORD 73 (2009/07) rev. 07-31-2009
11 of 11