ACORD 73 Instructions

ACORD 73 (2009/07) rev. 07-31-2009 1 of 11

Section Name Field Name Field and/or Section Description
TITLE ACORD 73 (2009/07) Solid Fuel Questionnaire -Supplement to Residential Section The title of the form. 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 2 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 3 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 4 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 nonprofessional.
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 5 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 6 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 7 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 8 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 9 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 10 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.
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

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