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

Masonry Manufactured Other

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?

 YES
 NO

3. What is your fireplace facing?


Brick Marble Other

4. Do you have glass doors on your fireplace?


Yes No

5. Does your chimney have a cap?


Yes No

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


Yes No

7. What floor is your fireplace on?


First floor Second floor Basement

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


Crawlspace Slab

9. Is there a gas source present?


Yes No

10. What type of gas will you burn?


Natural Propane

11. Does your fireplace draw well?


Yes No

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

Name of salesperson who assisted you (if applicable):