a Mark Fr: Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirmatin Email: Cnfirm Via: ZIP: Quickie 2 Lite January 2018 EIQ2X Submitting fr: Ship T: Attentin: Address: Address: Ship T City: Qute Fax Email Ship T Phne: ( ) Fax: ( ) Optin # HCPCS Definitin Price a Optin # HCPCS ST: ADDITIONAL SHIPPING INFORMATION The HCPCS CODES prvided are based n cde verificatin thrugh PDAC r ur interpretatin f the cde definitins. The use f HCPCS CODES des nt ensure cverage r payment. Fr cverage infrmatin, verify the apprpriate payer's cverage plicy. Specificatins are subject t change withut ntice 1. FRAME PO#: Definitin Order ZIP: Price E1236 cding still applies fr EIQ2X with sizes 14" r less. 002WM58 002IN04 K0005 Base mdel Quickie 2 Lite QLT $2,120.00 Transit Optin 002TO49 K0108 Transit System WC19 $350.00 Attitude Bike (Optinal) Attitude Bike bundle Fixed Frnt & Nn Hemi nly See Order Frm Frame Style (265 lbs. Weight Capacity) See figure 1. Measure frm frnt frame t flr 002FS31 Swing Away Frame 002FS32 Fixed Frnt 70 002FS33 Fixed Frnt 80 See FIGURE 2 Frame inset is the distance frm the utside f the seat tube t the utside f the ftrest. Ftrest width = frame width minus 2. 002FF1 0" 002FF2 Frame Inset (Fixed Frnt Only) 1" N/A fr 14" and 15" Wide using cmpsite angle adj ftrest 2. SIZE / SEATING Frame Width Frame Depth See FIGURE 2 Measured frm utside f seat tube t the utside f ppsite seat tube. If grwth is desired Seat Depth (*) may be rdered up t 2" smaller n swing away frames and up t 3" n fixed frnt frames. Please refer t matrix 002W5 14" in page 8 f Appendix regarding frame Depth Vs seat Depth. 002W6 15" 002FD5 14" 002W7 16" 002FD6 15" 002W8 17" 002FD7 16" (*) 002W9 18" 002FD8 17" (*) 002W10 19" 002FD9 18" (*) 002W11 E2201 20" $500.00 002FD10 002FD36 19" (*) 20" (*) Seat Depth See FIGURE 1 and Seat Squeeze Matrix Measured frm back canes t frnt Seat Sling edge f uphlstery. 002SL1 Standard Seat Sling 002SD7 14" Frnt f seat sling 2" behind 002SL6 Omit Seat Sling -$15.00 frnt edge f frame. 002SD8 002SD9 15" 16" JAY Cushins (Optinal) T rder any JAY cushins n-chair, please see the JAY price list. 002SD10 17" Cushin name r part number must be filled ut with desired width and depth 002SD11 18" JAY Bundled Cushin 002SD72 19" $75.00 002JC20 Cushin Name r Part # Price List 002SD13 E2203 20" $550.00 Width: Depth: 002CU1 E0669 Cushin 2" Cushin $120.00 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Page 1
Figure 1 Figure 2 2. SIZE / SEATING (CONT) Seat Squeeze Matrix Seat Depth Max Seat Squeeze 14"-15" 2.0" 16"-19" 2.5" 20" 3.0" 3. CASTERS / SEAT HEIGHT Frnt Seat Height 20" Max height fr Fixed frnt. 20.5"-21" Only available in Swing Away 002SH42 14.5" 002SH18 18.0" 002SH12 15.0" 002SH20 18.5" 002SH13 15.5" 002SH21 19.0" 002SH14 16.0" 002SH23 19.5" 002SH15 16.5" 002SH24 20.0" 002SH16 17.0" 002SH26 20.5" 002SH17 17.5" 002SH27 21.0" Caster Frk 002CF65 Multiple Psitin 002CF69 Multiple Psitin Single Sided Frk 002CF53 E1015 Frg Legs Suspensin (0-100 lbs) 002CF54 E1015 Frg Legs Suspensin (101-190 lbs) 002CF55 E1015 Frg Legs Suspensin (191-265 lbs) Multi Psitin Single side Frg Leg $150.00 002CW1 002CW3 002CW31 002CW72 002CW44 002CW64 4" x 1.5" Aluminum Sft Rll $185.00 002CW5 5" Lw Prfile Plyurethane 002CW51 5" Micr Lighted $85.00 002CW6 002CW65 002CW7 002CW66 002CW34 002CW33 002CW35 002CW68 E2219 E2219 E2214 E2215 Caster Wheels 3" Micr 4" Lw Prfile Plyurethane 4" Micr Lighted $70.00 4" x 1" Aluminum Plyurethane E2219 4" x 1.25" Semi Pneumatic $55.00 E2219 5" Sft Rll (Grey) N/A w/ Frg Legs 5" x 1" Aluminum Plyurethane 5" x 1.5" Semi-Pneumatic 5" x 1.5" Aluminum Sft Rll 6" Plyurethane 6" Pneumatic 6" x 1.5" Semi Pneumatic 6" x 1.5" Aluminum Sft Rll $85.00 $195.00 $75.00 $85.00 $205.00 3 2 1 Frnt Seat Height Matrix Caster Husing 002CP15 Integral Caster Husing 002CP12 Hemi Integral Cstr Husing Subtract 2" frm Standard Frnt STFH Matrix Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Page 2
4. REAR WHEELS / SEAT HEIGHT Rear Seat Height Rear Wheel Type (Cnt) 13" & 13.5" N/A w/ transit * Omit Rear wheel will default chair cnfiguratin set up t a 24" wheel. 002RH11 13.0" 002RH18 16.5" 002RW25 Omit Rear Wheel and Axle * -$55.00 002RH12 13.5" 002RH19 17.0" 002RW49 Omit Rear Wheel (Use w/24" Xtender) 002RH13 14.0" 002RH26 17.5" 002RW111 Omit Rear Wheel (Use w/22" Xtender) 002RH14 14.5" 002RH20 18.0" 002RH15 15.0" 002RH27 18.5" 002RH16 15.5" 002RH21 19.0" 002RH17 16.0" 002RH37 19.5" Please select ne f the fllwing handrim ptins 002XH5 Plastic Cated 002AX1 002AX11 002XT5 002XA8 002XA9 002XA2 002XT6 002XT7 002XT4 002XH6 002XA10 002XA11 002XA4 Axle Quick Release Steel 002RT3 Full Ply Xtender Pwer Assist (265 weight capacity) E2213 E2213 Quad Quick Release Muntain Wheel nly 22" Xtender Pwer Assist JWX-2 NICKEL 22" Xtender Pwer Assist JWX-2 LITHIUM 24" Xtender Pwer Assist JWX-2 NICKEL 24" Xtender Pwer Assist JWX-2 LITHIUM Stainless Steel Xtender - Other Optins Spare NiMH Pwer Pack - NICKEL Spare Li-in Pwer Pack - LITHIUM Xtender Wheel Optins SPARE 22" Lite Spke Pneu Alum SPARE 22" Lite Spke Pneu Plastic SPARE 24" Lite Spke Pneu Alum $125.00 $7,895.00 $8,695.00 $8,695.00 SPARE 24" Lite Spke Pneu Plastic Rear Wheel Type $7,895.00 $1,395.00 $1,795.00 See availability matrix. Nt applicable w/ Xtender Pwer Assist Optin. Omit Handrim Optin may nt be 002HR7 Ultra Lightweight Wheels nly available w/ Alum Andized Handrim available n all wheels 002RW103 20" Mag Wheel 5 Spke 8 Oblique N/A w/ Xtender, Only 002HR8 available with 24" r 26 " r Lite Spke 002RW104 22" Mag Wheel 5 Spke rims. $325.00 002RW102 002RW90 24" Mag Wheel 5 Spke 20" Lite Spke Wheel $200.00 Rear Seat t Flr Height Matrix 002RW91 22" Lite Spke Wheel $200.00 Nte: These values are representative f a 16" seat depth with 1" f seat squeeze and standard axle plate. Due t variances caused by seat angle, rear seat height ranges may 002RW92 24" Lite Spke Wheel shift up r dwn by as much as 1/2". Call custmer service r nline cnfiguratr fr mre 002RW93 25" Lite Spke Wheel infrmatin. 002RW94 26" Lite Spke Wheel $80.00 Wheel/Tire 13.0 13.5 14.0 14.5 15.0 15.5 16.0 16.5 17.0 17.5 18.0 18.5 19.0 19.5 002RW77 22" Ultra Lightweight Spke Wheel $250.00 20" All X X X X X X X X N/A N/A N/A N/A N/A N/A 002RW78 24" Ultra Lightweight Spke Wheel $250.00 22" Ply N/A N/A X X X X X X X X N/A N/A N/A N/A 002RW28 22" Spinergy SPOX Black $820.00 22" Pneu N/A N/A N/A X X X X X X X X N/A N/A N/A 002RW95 24" Spinergy SPOX Black $820.00 24" Pneu N/A N/A N/A N/A X X X X X X X X N/A N/A 002RW96 25" Spinergy SPOX Black $820.00 24" All but Pneu N/A N/A N/A N/A X X X X X X X X N/A N/A 002RW97 26" Spinergy SPOX Black $820.00 25" SHOX N/A N/A N/A N/A X X X X X X X X N/A N/A 002RW32 22" Spinergy LX Black $1,025.00 25" All but SHOXN/A N/A N/A N/A N/A X X X X X X X X N/A 002RW98 24" Spinergy LX Black $1,025.00 26" All N/A N/A N/A N/A N/A N/A X X X X X X X X 002RW99 002RW40 002RW50 25" Spinergy LX Black 26" Spinergy LX Black 24" Muntain $1,025.00 $1,025.00 $250.00 002RT1 002RT39 002RT27 002RT21 002RT12 002HR4 002HR30 E2213 Rear Wheel Tire Pneumatic Airless Insert High-Pressure Clincher Black Aluminum Andized $80.00 Natural Fits available in 22", 24", and 25". Ultra lightweight wheels ONLY available w/ alum an handrim. Natural Fit w/ 5 spke MAG nly available in 24". Nt all handrims available n all wheels 002RT2 002HR1 002HR22 002HR25 002HR23 002HR31 002HR32 002HR26 002HR27 002HR28 002HR24 Pneumatic Knbby V-TRAK Schwalbe Marathn Plus Evlutin $135.00 002RT38 E2218 SHOX Perfrmance Ply Muntain Tire Only available n 24" Muntain Rear Wheel Handrim Plastic Cated -N/A n every rim Natural Fit - Standard Grip Natural Fit - N Thumb Grip Natural Fit - Super Grip Natural Fit LT- Standard Grip Natural Fit LT- Super Grip Natural Fit LT - N Thumb Grip The Surge - Oval w/griptin Strip The Surge LT - Oval w/griptin Strip Q-Grip Neprene Cated Spinergy Flex Rim Available n 24" & 25" Spinergy LX wheel $395.00 $375.00 $415.00 $475.00 $375.00 $385.00 $415.00 $325.00 $650.00 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Page 3
4. REAR WHEELS / SEAT HEIGHT (cnt) Tire Pneumatic Wheel 5 Spke Mag 20,22,24 Mag 20,22,24 Lite Spke 20,22,24,26 Ultra Lt wt Spinergy 24,26 002CI1 0 00217CI 2 (default) 002CI3 4 Pneumatic w/airless Insert 20,22,24 20,22,24 20,22,24,26 24,26 Full Ply Tire 20,22,24 20,22,24 20,22,24 Center f Gravity Preset High Pressure Clincher black Knbby V-TRAK Schwalbe Marathn 22,24,25,26 24 24,25,26 22,24 22,24 22,24,26 24 24,25,26 002CC2 002CC3 002CC4 002CC5 1.0" (default) 1.5" 2.0" 2.5" SHOX Perfrm. Ply 20,22,24 24,25 24,25 002CC6 3.0" 20"= 451 mm 22" = 501 mm 24" = 540 mm 25" = 559 26" = 590 002CC7 3.5" Camber 5. WHEEL LOCKS Wheel Lck N Gs may exist depending n wheel size and psitin. Erg & cmpact N/A w/ 13"-14" frame depth 002WL46 002WL50 002WL64 002WL24 002WL23 High Munt Push High Munt Pull 002WL75 Erg Scissr 002WL10 Cmpact Unilateral Wheel Lck Right Unilateral Wheel Lck Left Omit $125.00 $300.00 $300.00 N/A w/ erg scissr r cmpact wheel lcks 002EH7 E0961 Extensin Handle (Pair) $70.00 002WL12 E0974 Wheel Lck Optin D Nt Munt Extensin Handle Grade Aid Grade Aid Only available w/ high munt push r pull t lck wheel lcks n pneumatic r pneumatic w/ airless tire ptins 002GA1 $150.00 6. HANGER & FOOTREST Swing - Away Hangers Ftplate munts with Extensin Tube using clamping hardware 002H145 002H139 60 Swing In/Out Hanger 70 Swing In/Out Hanger 002H141 80 Swing In/Out Hanger 002H32 Omit Hanger and Ftplate Ftrest Extensin Tubes See Extensin matrix fr leg length range 002E1 Shrt 002E2 Medium 002E5 Lng Extensin Matrix -$15.00 Z-finity Hangers/Ftrest System (Maximum weight capacity fr Z-Finity ftrests is 165 lbs) Sme interference may exist in certain cnfiguratins. 002H162 Z-finity Hanger STD Z-finity Ftrest Munt 002DI22 Direct Hanger Mt/Fixed Frame - High 002DI23 Direct Hanger Mt/Fixed Frame - Lw 002DI24 Extensin Tube Munt 002DI20 002DI21 Z-finity Ftrest Pivt Arm Shrt 2" Lng 3 1/4" Z-finity Ftplate Sme interference may exist in certain cnfiguratins. 002F320 K0040 Multi Angle Adjustable (Pair) (nt avail. w/8"-9" widths) $185.00 002F321 K0040 Angle Adjustable Platfrm Ftbard $150.00 002F6 Omit Ftplate Z-finity ExtensinTube Length (When Chsing Ext. Tube Munt) 002E62 Hemi Shrt 002E1 Shrt 002E2 Medium 002E5 Lng Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Page 4
Heel lp r leg strap nt included, See Ftplate Optins Sectin 002F1 Cmpsite (14"-20"w) 002LO07 12.0" 002LO16 16.5" 002F271 K0040 Cmpsite Angle Adj (16"-20"w) $150.00 002LO08 12.5" 002LO17 17.0" 002F3 K0040 Aluminum Angle Adj (14"-20"w) $185.00 002LO09 13.0" 002LO18 17.5" 002F48 K0040 Platfrm Flip Up $190.00 002LO10 13.5" 002LO19 18.0" 002F245 Standard Back type ptins: 002PH6 Integral Push Handles 002PH11 002PH2 002PH17 K0040 Angle Adj Back type ptins: 002F250 002HL1 002HL5 002BT10 002BT84 002PH12 002PH5 K0040 E0951 K0038 Tubular Flip Up Fixed frnt frame nly Aut Fld Angle Adj Fixed frnt frame nly Ftplate Optins Heel Lp Leg Strap Ftplates Back Type Standard (9"-20") Angle Adjustable Back (3" & 4") Back Pst Optins Integral Push Handles w/8 Medium & Tall nly, N/A w/ Angle Adj Back Omit Push Handles Omit Push Handles w/8 Medium & Tall nly, N/A w/ Angle Adj Back Flding Push Handle with Ht. Adj. Back N/A w/angle Adj Back Fld-Dwn Push Handles N/A w/ standard Uphlstery and J3 Back 6. HANGER & FOOTREST (cnt) $100.00 $200.00 $30.00 $35.00 7. BACKREST / SEATING $185.00 $25.00 $225.00 $100.00 Recmmend 2" ftrest clearance t grund surface 002LO11 14.0" 002LO20 18.5" 002LO12 14.5" 002LO21 19.0" 002LO13 15.0" 002LO22 19.5" 002LO14 15.5" 002LO23 20.0" 002LO15 16.0" 002LO24 20.5" 002JB01 Lwer Leg Length Setting JAY Back (Optinal) J3 Back (See J3 Order Frm) Military Service Patches (Optinal) Price List N/A with standard Uphlstery 002VU2 Army Patch 002VU4 Air Frce Patch 002VU12 Cast Guard Patch 002VU1 Marines Patch 002VU3 Navy Patch 002VU5 Purple Heart Patch 002VU9 Purple Heart with Army Patch $145.00 002VU11 Purple Heart with Air Frce Patch $145.00 002VU13 Purple Heart with Cast Guard Patch $145.00 002VU8 Purple Heart with Marines Patch $145.00 002VU10 Purple Heart with Navy Patch $145.00 Angle Adjustable Back Setting Back Height (Std r Angle Adjustable) 002AH1 3" Pivt Pint Setting See Matrix 002AH2 4" Pivt Pint Setting 002B1 Lw Select desired setting 002B5 Medium -14-12 -9-7 -1 0 +4 +5 002B9 Tall Back Height Setting (Std r Angle Adjustable) 17" max height fr shipping. 21" nly available w/ Ang Adj Back 002UX4 9" 002UX18 16" 002UX6 10" 002UX20 17" 002UX8 11" 002UX22 18" 002UX10 12" 002UX24 19" 002UX12 13" 002UX26 20" 002UX14 14" 002UX28 21" (*) 002UX16 15" Backrest Height Matrix Std EXO uphlstery and Tensin adjustable binding is always black. 002BU1 Standard Uphlstery 002BU95 Standard Uphlstery EXO Clr Binding: Silver Orange Red Blue Backrest Tensin Adjust Ballistic 002BU70 E2611 *Reference 186BU70 fr billing 002BU89 E2611 Backrest Uphlstery $15.00 $315.00 Backrest Tensin Adj EXO *Reference XXXBU89 fr billing $330.00 Clr Binding: Silver Orange Red Blue 002BU71 E2611 002BU82 002BU14 E2611 Backrest Tensin Adjust 3DX Vented *Reference 186BU71 fr billing Jay GO Backrest Omit Back Uphlstery $15.00 $330.00 $400.00 -$15.00 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Page 5
8. ARMREST / SIDE GUARDS Padded Swing Away Sme limitatins when used w/ angle adj back in the rear mst setting Erg armpad nly available with Single pst Height adj & Flip back armrest E0973 Padded Swing-Away STD (9" t 13") $210.00 002AM23 Desk Length - Classic (10") 002AA18 Setting 9" 10" 11" 12" 13" 002AM24 Full Length - Classic (14") 002AM27 Erg Pad (9.5"-13.5") Height Adjustable 4 Pint (FS) J3 munting bracket will cause interference with Flip Back Height Adj armrest. 002AA11 E0973 Single Pst Hgt. Adj. Std (8.5"-13.5") 002AA29 E0973 Single Pst Hgt. Adj. Lw (7"-11") 002AA65 E0973 Flip Back Height Adj LITE (8.5"-13.5") $285.00 $285.00 002SG33 002SG29 K0108 K0108 Armpad fr Height Adjustable Side Guard Plastic Standard (8.5" High) Plastic Lw (6.5" High) $140.00 $140.00 Omit Armrest 002AA14 Omit Armrest 9. KEY OPTIONS & ACCESSORIES Anti-Tip Psitining Belts 002AT1 E0971 Rear Anti-Tip ( w/ Xtender) $140.00 002A141 E0978 Belt 1.5" Aut Buckle w/clamps $70.00 002A117 E0978 Belt 2" Aircraft Buckle w/clamps Backpack 002A118 E0978 Belt 2" Aircraft Buckle Pad w/clamp $120.00 002A1 Quickie Backpack Black $65.00 002A120 K0108 Psitining Belt Slide Clamps $50.00 002A2 Quickie Kids Backpack Black $60.00 Spke Guards Seat Puch Only available w/ Muntain, and Lite Spke wheels 0021A01 Seat Puch Black /Charcal $50.00 Nt available with 5 spke MAG wheels 0024A01 K0065 Quickie Black Spke Guards $115.00 Additinal Cver & Pack Accessries 0024A02 K0065 Quickie Clear Spke Guards $115.00 0028A02 Gel Cver Hanger/Frame 0028A01 Gel Cver Swing Away Arm Miscellaneus 0028A03 Caddy $50.00 002IG2 Impact Guard Neprene $85.00 002LS14 K0038 Extra Leg Strap Black $35.00 0028A21 Tl Kit $45.00 10. COLOR Standard Frame Clrs 002C140 Aztec Gld 002C2 Black (Nt avail as base w/zebra) 002C141 Black Cherry 002C10 Black Opal 002C38 Blue Opal 002C36 Candy Blue 002C14 Candy Purple 002C35 Candy Red 002C142 Electric Blue 002C143 Evergreen 002C126 Glw 002C144 Green Apple 002C147 Ht Sparkle Pink 002C148 Mauve Pink 002C103 Rtbeer 002C114 Sparkle Silver 002C145 Sunrise Orange 002C113 Titanium Clr Paint 002C8 Yellw 002C116 002C151 002C150 002C149 002C152 002C112 002C43 002C42 002C108 Matte Frame Clrs Matte Black Matte Black Cherry Matte Electric Blue Matte Evergreen Matte Purple Custm Frame Clr Desert Camuflage Mssy Oak Camuflage Stars & Stripes Zebra (Chse abve base clr) Std with White unless abve base paint is chsen N/A w/ Black Sunrise Medical (US) LLC 2842 Business Park Ave. Fresn, CA 93727 USA Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Page 6