list: 27 Spain EUR Dealer Information Contact: Customer Code: Customer Name: Address 1: City: Post code: Phone: Fax: PO: Client Information First Name: Last Name: Diagnosis: Address 1: Address 2: Postal code: City: Country: Phone: e-mail: Client Measurements Weight: Height: 1) Upper leg length: 2) Chest Depth: 3) Seat pan to elbow: 4) Arm pit height: 5) Top of shoulders: 6) Top of head: 7) Elbow to Hand: 8) Chest width: 9) Knee to Foot: 10) Hip width: kg All specifications and prices are subject to change without notice. Please note that displayed prices are only valid if ordered with the wheelchair. Any parts ordered for service or future alterations will carry different prices and warranty. Rabobank Parkstad Limburg Rekening: 1238.24.184 IBAN: NL84RABO0123824184 BIC/SWIFT: RABONL2U europe@permobil.nl Permobil Europe B.V. De Doom 22 NL 6419 CX HEERLEN Phone: +31 (0)45 564 54 90 Fax: +31 (0)45 564 54 91 Page 1 of 7
Chassis Model 103005-99-0 X850 CORPUS EUR 13,058.00 User manual 103112-99-0 USER MANUAL EU X850 / CORPUS EUR - Drive unit 103029-99-0 DRIVE UNIT 15/KMH EUR - Charger connector 102226-99-0 CHARGER CONNECTOR XLR COMMON EUR - Colour covers 103174-99-0 COVERS X850 DARK BLUE METALLIC EUR - 103175-99-0 COVERS X850 DARK GREY METALLIC EUR - 103173-99-0 COVERS X850 RED METALLIC EUR - Extender 103012-99-0 POWERED WHEELBASE EXTENSION (815-1015MM) EUR 957.00 103011-99-0 FIXED WHEELBASE EXTENSION (815-1015MM) EUR - Wheels 103017-99-0 WHEELS (4 PCS) X850 DEEP PROFILE EUR 496.00 103016-99-0 WHEELS (4 PCS) X850 FINE PROFILE EUR - Accessories chassis Batteries 101999-99-0 BATTERIES, 97Ah, SET OF 2 EUR - Charger 104750-99-0 CHARGER JK MEDICO CCC410 EUR - Running time meter (+) 101957-99-0 RUNNING TIME METER C400/C500 EUR 126.00 Rear mirror Right (+) 103101-99-0 REAR VIEW MIRROR RIGHT EUR 77.00 Rear mirror Left (+) 103137-99-0 REAR VIEW MIRROR LEFT EUR 77.00 Luggage carrier (+) 105501-99-0 LUGGAGE BOX FACING BACK- WARDS EUR 357.00 105500-99-0 LUGGAGE BOX FACING FOR- WARD EUR 357.00 103019-99-0 LUGGAGE CARRIER EUR 357.00 Crutch holder Right (+) 100292-99-0 CRUTCH HOLDER RIGHT EUR 130.00 Crutch holder Left (+) 100293-99-0 CRUTCH HOLDER LEFT EUR 130.00 Rain cover (+) 101888-99-0 TARPAULIN/RAINCOVER FOR ALL MODLES EUR 108.00 101899-99-0 TARPAULIN FOR TRAX WITH ROLLBAR EUR 225.00 Remote stop (+) 104769-99-0 REMOTE STOP VR2/SAFEGATE EUR 517.00 User manual Remote stop (+) 104777-99-0 USER MANUAL ES REMOTE STOP EUR - Footplate Options (+) 101892-99-0 FOOTPLATE ADJUSTABLE TRAX EUR 147.00 Seat assembly Seat lift system 103022-99-0 POWERED SEAT LIFT X850 EUR 1,311.00 103033-99-0 SEAT HEIGHT FIXED X850 EUR - Seat assembly 103013-99-0 FIXED MOUNTING / NO SEAT SWIVEL X850 EUR - 103009-99-0 POWERED SWIVEL SEAT 2x90 EUR 1,017.00 Page 2 of 7
Seat assembly 103023-99-0 MANUAL SWIVEL SEAT 2x90 EUR 378.00 103035-99-0 POWERED ADJ.SEAT TILT 14 X850 EUR 1,491.00 Cabling (+) 100590-99-0 ACTUATOR CONTROL WIRING KIT TRAX EUR - Seat Seat 103146-99-0 SEAT 430x360 WITHOUT CUSHION (BACKR. 90-135 ) EUR - 103149-99-0 SEAT 430x410 WITHOUT CUSHION (BACKR. 90-135 ) EUR - 103154-99-0 SEAT 430x460 WITHOUT CUSHION (BACKR. 90-135 ) EUR - 103161-99-0 SEAT 430x510 WITHOUT CUSHION (BACKR. 90-135 ) EUR - 103167-99-0 SEAT 430x560 WITHOUT CUSHION (BACKR. 90-135 ) EUR - 103155-99-0 SEAT 480x460 WITHOUT CUSHION (BACKR. 90-135 ) EUR - 103162-99-0 SEAT 480x510 WITHOUT CUSHION (BACKR. 90-135 ) EUR - 103168-99-0 SEAT 480x560 WITHOUT CUSHION (BACKR. 90-135 ) EUR - Seat cushion 103293-99-0 SEAT CUSHION 420x370 TEXTILE (MESH) EUR - 103294-99-0 SEAT CUSHION 450x420 TEXTILE (MESH) EUR - 103296-99-0 SEAT CUSHION 450x500 TEXTILE (MESH) EUR - 103297-99-0 SEAT CUSHION 450x560 TEXTILE (MESH) EUR - 103299-99-0 SEAT CUSHION 500x500 TEXTILE (MESH) EUR - 103300-99-0 SEAT CUSHION 500x560 TEXTILE (MESH) EUR - 103387-99-0 SEAT CUSHION 420x370 VINYL EUR - 103388-99-0 SEAT CUSHION 450x420 VINYL EUR - 103389-99-0 SEAT CUSHION 450x500 VINYL EUR - 103390-99-0 SEAT CUSHION 450x560 VINYL EUR - 103391-99-0 SEAT CUSHION 500x500 VINYL EUR - 103392-99-0 SEAT CUSHION 500x560 VINYL EUR - 103292-99-0 WITHOUT SEAT CUSHION EUR -131.00 Backrest 101010-99-0 BACKR. 340x535 EUR - 100737-99-0 BACKR. 340x605 EUR - 101011-99-0 BACKR. 390x535 EUR - 100738-99-0 BACKR. 390x605 EUR - 101012-99-0 BACKR. 440x535 EUR - 100739-99-0 BACKR. 440x605 EUR - 100740-99-0 BACKR. 340 WIDE WITHOUT PLATE EUR -166.00 100741-99-0 BACKR. 390 WIDE WITHOUT PLATE EUR -166.00 100742-99-0 BACKR. 440 WIDE WITHOUT PLATE EUR -166.00 101962-99-0 BACK BIO-MECH. 390x605 EUR 296.00 101963-99-0 BACK BIO-MECH. 440x605 EUR 296.00 Backrest cushion 103310-99-0 BACKREST CUSHION 340x535 TEXTILE (MESH) EUR - 103311-99-0 BACKREST CUSHION 340x605 TEXTILE (MESH) EUR - 103312-99-0 BACKREST CUSHION 390x535 TEXTILE (MESH) EUR - 103313-99-0 BACKREST CUSHION 390x605 TEXTILE (MESH) EUR - 103314-99-0 BACKREST CUSHION 440x535 TEXTILE (MESH) EUR - 103315-99-0 BACKREST CUSHION 440x605 TEXTILE (MESH) EUR - 103322-99-0 BACKREST CUSHION 340x535 VINYL EUR - 103323-99-0 BACKREST CUSHION 340x605 VINYL EUR - 103324-99-0 BACKREST CUSHION 390x535 VINYL EUR - 103325-99-0 BACKREST CUSHION 390x605 VINYL EUR - 103326-99-0 BACKREST CUSHION 440x535 VINYL EUR - 103327-99-0 BACKREST CUSHION 440x605 VINYL EUR - 103309-99-0 WITHOUT BACKREST CUSHION EUR -164.00 Cover backrest (+) 104826-99-0 COVERS / WITHOUT BACKREST EUR - Adjustment backrest 102221-99-0 MANUAL ADJUST. BACKREST 90-135 LOWRIDER EUR - 104653-99-0 MANUAL ADJUSTMENT BACK- REST INCL GAS SUSP 250N EUR 404.00 Page 3 of 7
Adjustment backrest 104654-99-0 MANUAL ADJUSTMENT BACK- REST INCL GAS SUSP 350N EUR 404.00 103180-99-0 POWERED ADJ. BACKREST 90-135 EUR 1,073.00 Armrest Right 103331-99-0 ARMREST 250MM,RIGHT TEXTILE (BLACK TRIVERA) EUR - 103339-99-0 ARMREST 250MM,RIGHT VINYL (PU FOAM) EUR - 103333-99-0 ARMREST 300MM,RIGHT TEXTILE (BLACK TRIVERA) EUR - 103341-99-0 ARMREST 300MM,RIGHT VINYL (PU FOAM) EUR - 103335-99-0 ARMREST 350MM,RIGHT TEXTILE (BLACK TRIVERA) EUR - 103343-99-0 ARMREST 350MM,RIGHT VINYL (PU FOAM) EUR - 103337-99-0 ARMREST 400MM,RIGHT TEXTILE (BLACK TRIVERA) EUR - 103345-99-0 ARMREST 400MM,RIGHT VINYL (PU FOAM) EUR - 101351-99-0 WITHOUT ARMREST, RIGHT (BODY AND UPHOLSTERY) EUR -52.00 Armrest Left 103330-99-0 ARMREST 250MM,LEFT TEXTILE (BLACK TRIVERA) EUR - 103338-99-0 ARMREST 250MM,LEFT VINYL (PU FOAM) EUR - 103332-99-0 ARMREST 300MM,LEFT TEXTILE (BLACK TRIVERA) EUR - 103340-99-0 ARMREST 300MM,LEFT VINYL (PU FOAM) EUR - 103334-99-0 ARMREST 350MM,LEFT TEXTILE (BLACK TRIVERA) EUR - 103342-99-0 ARMREST 350MM,LEFT VINYL (PU FOAM) EUR - 103336-99-0 ARMREST 400MM,LEFT TEXTILE (BLACK TRIVERA) EUR - 103344-99-0 ARMREST 400MM,LEFT VINYL (PU FOAM) EUR - 101353-99-0 WITHOUT ARMREST, LEFT (BODY AND UPHOLSTERY) EUR -52.00 Armrest height adjustment 101744-99-0 ARMRESTS OVER 50MM HEIGHT ADJUSTMENT (STD) EUR - 100523-99-0 ARMRESTS OVER 100MM HEIGHT ADJUSTMENT EUR 62.00 Armrests reinforcement (+) 101510-99-0 ARMREST REINFORCEMENT KIT HIGH EUR 115.00 Armrest mounting 101003-99-0 ARMRESTS HIGH MOUNTED EUR - 101002-99-0 ARMRESTS LOW MOUNTED EUR - Accessories seat Headrest (+) 103460-99-0 HEAD SUPPORT "ERGO" TEXTILE (BLACK TRIVERA) EUR 358.00 104130-99-0 HEAD SUPPORT, ADJUSTABLE TEXTILE (BLACK TRIVERA) EUR 215.00 104131-99-0 HEAD SUPPORT, ADJUSTABLE VINYL EUR 215.00 100712-99-0 WITHOUT HEADREST * EUR - Accessories rail headrest (+) 103697-99-0 ACCESSORIES RAIL HEAD SUPPORT EUR 43.00 Lateral support (+) 103050-99-0 LATERAL SUPPORTS SMALL(A) 150x140 TEXTILE (MESH) EUR 261.00 103056-99-0 LATERAL SUPPORTS MED(F) 220x90 TEXTILE (MESH) EUR 267.00 103062-99-0 LATERAL SUPPORTS LARGE(E) 220x150 TEXTILE (MESH) EUR 272.00 Mounting set lateral support (+) 103425-99-0 MOUNTING KIT LATERAL SUPPORTS (BACKREST 340MM) EUR - Thigh support (+) 103092-99-0 THIGH SUPPORTS TEXTILE (MESH) 110x90 SMALL (B) EUR 329.00 103094-99-0 THIGH SUPPORTS TEXTILE (MESH) 165x120 MEDIUM (J) EUR 335.00 103095-99-0 THIGH SUPPORTS TEXTILE (MESH) 200x90 LARGE (C) EUR 341.00 102977-99-0 THIGH SUPPORTS TEXTILE (MESH) 300x90 XLARGE (G) EUR 346.00 Hip support (+) 103077-99-0 HIP SUPPORTS SMALL (B) 110x90 TEXTILE (MESH) EUR 329.00 103079-99-0 HIP SUPPORTS MEDIUM (A) 150x140 TEXTILE (MESH) EUR 335.00 103081-99-0 HIP SUPPORTS LARGE (C) 200x90 TEXTILE (MESH) EUR 341.00 103083-99-0 HIP SUPPORTS X LARGE (D) 200x200 TEXTILE (MESH) EUR 346.00 Seatbelt (+) 104514-99-0 BELT 2-POINT LARGE NONPAD BODYPOINT INCL BRACK UT EUR 99.00 104516-99-0 BELT 2-POINT LARGE PADDED BODYPOINT INCL BRACK UT EUR 142.00 Page 4 of 7
Seatbelt (+) 104518-99-0 BELT 2-POINT MEDIUM NONPA D BODYPOINT INCL BRACK UT EUR 92.00 104520-99-0 BELT 2-POINT MEDIUM PADDE D BODYPOINT INCL BRACK UT EUR 134.00 100518-99-0 SAFETY BELT,BUCKLE EUR 49.00 100519-99-0 SAFETY BELT,AUTOTENSION EUR 118.00 100600-99-0 SAFETY BELT,AUTOTENSION LONG VERSION EUR 118.00 100529-99-0 SAFETY BELT,4-POINT EUR 202.00 Mounting position seatbelt (+) 105010-99-0 MOUNT POS SEATBELT ROLL RIGHT EUR - 105011-99-0 MOUNT POS SEATBELT ROLL LEFT EUR - Support handles set (+) 103651-99-0 TRANSFER HANDLES, SET (pair) UNI-TRACK EUR 141.00 Stump support (+) 103067-99-0 STUMP SUPPORT SMALL (A) 150x140 TEXTILE (MESH) EUR 131.00 103068-99-0 STUMP SUPPORT MEDIUM (J) 165x120 TEXTILE (MESH) EUR 136.00 103070-99-0 STUMP SUPPORT LARGE (H) 170x175 TEXTILE (MESH) EUR 141.00 103071-99-0 STUMP SUPPORT XLARGE (D) 200x200 TEXTILE (MESH) EUR 147.00 Mounting position stump support (+) 105009-99-0 MOUNT POS AMPUTATION SUPP -ORT LEFT EUR - 105008-99-0 MOUNT POS AMPUTATION SUPP -ORT RIGHT EUR - Accessories rail (+) 105675-99-0 UNITRACK BAR ACCESSORIE -100 EUR - 105676-99-0 UNITRACK BAR ACCESSORIE -50 EUR - 103176-99-0 ACCESSORIES RAIL EUR - 103177-99-0 ACCESSORIES RAIL +50 EUR - 103178-99-0 ACCESSORIES RAIL +100 EUR - 103468-99-0 WHITOUT ACCESSORIES RAIL EUR - Roll bar (+) 103171-99-0 ROLL BAR LOW EUR 688.00 Support handle armrest (+) 103194-99-0 SUPPORT HANDLE ARMREST CORPUS EUR 114.00 Support armrest inside Right (+) 101263-99-0 ARMREST SUPPORT,VINYL RIGHT INSIDE EUR 74.00 Support armrest inside Left (+) 101264-99-0 ARMREST SUPPORT,VINYL LEFT INSIDE EUR 74.00 Support armrest outside Right (+) 101261-99-0 ARMREST SUPPORT,VINYL RIGHT OUTSIDE EUR 74.00 Support armrest outside Left (+) 101262-99-0 ARMREST SUPPORT,VINYL LEFT OUTSIDE EUR 74.00 Incontinence protection (+) 102808-99-0 INCONTINENCE PROTECTION 430x360/430x410 EUR 46.00 102807-99-0 INCONTINENCE PROTECTION 430x460/430x510/430x560 EUR 49.00 102809-99-0 INCONTINENCE PROTECTION 480x410 EUR 49.00 102806-99-0 INCONTINENCE PROTECTION 480x460/480x510/480x560 EUR 55.00 Comfort seat cushion (+) 104739-99-0 SEAT CUSHION COMFORT 450x420,TEXTILE (MESH) EUR 285.00 104740-99-0 SEAT CUSHION COMFORT 450x450,TEXTILE (MESH) EUR 285.00 104741-99-0 SEAT CUSHION COMFORT 450x530,TEXTILE (MESH) EUR 285.00 104742-99-0 SEAT CUSHION COMFORT 450x560,TEXTILE (MESH) EUR 285.00 104744-99-0 SEAT CUSHION COMFORT 500x530,TEXTILE (MESH) EUR 285.00 104743-99-0 SEAT CUSHION COMFORT 500x500,TEXTILE (MESH) EUR 285.00 104745-99-0 SEAT CUSHION COMFORT 500x560,TEXTILE (MESH) EUR 285.00 104725-99-0 SEAT CUSHION COMFORT 450x500,TEXTILE (MESH) EUR 285.00 Comfort seat plate (+) 101227-99-0 SEAT PLATE COMFORT 430x460/510 EUR 147.00 Armrest pouch Right (+) 100671-99-0 ARMREST POUCH,RIGHT EUR - Armrest pouch Left (+) 100672-99-0 ARMREST POUCH,LEFT EUR - Page 5 of 7
Seat frame pouch (+) 102588-99-0 SEATFRAME POUCH EUR 30.00 Bag hooks (+) 105805-99-0 BAG HOOKS OPEN EUR 32.00 Back pack (+) 102059-99-0 BACK PACK INCL. HOOKS EUR 294.00 Cup/phone holder (+) 103044-99-0 CUP/PHONE HOLDER EUR 20.00 Lumbar support (+) 101972-99-0 LUMBAR SUPPORT,AIR EUR 148.00 Crutch holder (+) 101956-99-0 CRUTCH HOLDER EUR 116.00 Holder oxygen bottle (+) 101964-99-0 HOLDER OXYGEN BOTTLE CORPUS EUR 212.00 User control User control 101352-99-0 NON STANDARD STEERING EUR - 103024-99-0 CONTROL PANEL WITH SMALL JOYSTICK EUR - 103025-99-0 CONTROL PANEL WITH BIG JOYSTICK EUR 400.00 Joystick holder (+) 100819-99-0 SIDE STEERING,RIGHT PARALLEL SWING AWAY EUR - 100824-99-0 SIDE STEERING,LEFT PARALLEL SWING AWAY EUR - Tumble switches for switchbox (+) 100524-99-0 TUMBLE SWITCHES FOR SWITCH BOX SEAT FUNCTIONS EUR 77.00 Attendant control Attendant control (+) 104825-99-0 JOYSTICK ATTENDNAT X850 BIG JOYSTICK EUR 1,883.00 104697-99-0 JOYSTICK ATTENDNAT X850 SMALL JOYSTICK EUR 1,259.00 Mounting position attendant control (+) 105017-99-0 MOUNT POS ATTENDANT CON- TROL LEFT EUR - 105016-99-0 MOUNT POS ATTENDANT CON- TROL RIGHT EUR - Cable attendant control (+) 104698-99-0 CABLE SET 2 CONTROL PANELS EUR - Supplementary accessories Joystick knobs (+) 101165-99-0 JOYSTICK KNOB BALL SMALL EUR 12.00 100962-99-0 JOYSTICK KNOB BALL BIG EUR 15.00 100960-99-0 JOYSTICK KNOB CHIN CUP EUR 15.00 100964-99-0 JOYSTICK KNOB MUSHROOM EUR 26.00 100963-99-0 JOYSTICK KNOB SOFT BALL EUR 26.00 100965-99-0 JOYSTICK KNOB STICK EUR 26.00 100961-99-0 JOYSTICK KNOB T-GRIP EUR 40.00 105442-99-0 JOYSTICK SOFTBALL BLACK WITH CONE EUR 23.00 Chair Order Policy: For other options and special adaptations, please call Permobil for further details. Please also refer to Permobil s Delivery Policy for further information. Your order cannot be processed without the following: - The client s name - The client s measurements - The client s weight Page 6 of 7
For your ordering, please sign below with date and company stamp. Signature: Date: Company Stamp: An order confirmations will be provided by Permobil summarizing the items selected. Please review this carefully. Page 7 of 7