Your Name (required)

Your Email (required)

Your Address

City, State, Zip

Measurement for “A” (depth of mantel shelf)

Measurement for “B” (depth of trim below shelf)

Measurement for “C” (width of fireplace – refer to illustration above)

Measurement for “D” (height of fireplace – refer to illustration above)

Measurement for “E” (above fireplace, below trim – refer to illustration above)

Measurement for “F” (top of fireplace opening to bottom of mantel shelf – refer to illustration above)

Measurement for “G” (width of space to immediate left or right of fireplace, refer to illustration above)

Measurement for “H” (width of back wall)

Measurement for “I” (depth of floor of your fireplace, taken from FRONT to BACK floor area of fireplace)

Measurement for “J” (center width of floor of your fireplace)

1. Fireplace type
MasonryManufacturedOther

If you choose “other” above for your fireplace type, please share the name of the manufacturer with us below.

2. Are there louvers above your opening?
YESNO

3. What is your fireplace facing?

BrickMarbleOther

4. Do you have glass doors on your fireplace?

YesNo

5. Does your chimney have a cap?

YesNo

6. Has your fireplace been cleaned in the past 12 months?

YesNo

7. What floor is your fireplace on?

First floorSecond floorBasement

8. Is your fireplace on a crawlspace or a slab?

CrawlspaceSlab

9. Is there a gas source present?

YesNo

10. What type of gas will you burn?

NaturalPropane

11. Does your fireplace draw well?

YesNo

Best daytime number to reach you (please include area code):

Name of salesperson who assisted you (if applicable):