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 March 2017 EIQ2X Submitting fr: Ship T: Attentin: Address: Qute Fax Email Ship T Phne: ( ) Fax: ( ) Optin # HCPCS Definitin Price a Optin # HCPCS ST: Order 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. 1. FRAME PO#: Address: Ship T City: ADDITIONAL SHIPPING INFORMATION Definitin ZIP: Price E1236 cding still applies fr EIQ2X with certain sizes 002WM58 K0005 Quickie 2 Lite $2,075.00 002TO49 Transit System WC19 $350.00 002IN04 Base mdel Transit Optin Attitude Bike (Optinal) Attitude Bike bundle Fixed Frnt & Nn Hemi nly See Order Frm See figure 1. Measure frm frnt frame t flr 002FS31 Swing Away Frame 002FS32 Fixed Frnt 70 002FS33 Fixed Frnt 80 Frame Inset (Fixed Frnt Only) 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 Style (265 lbs. Weight Capacity) 1" NA fr 14" and 15" Wide using cmpsite angle adj ftrest 2. SIZE / SEATING See FIGURE 2 Measured frm utside f seat tube t the utside f ppsite seat tube. 002W5 14" 002W6 15" 002W7 16" 002W8 17" 002W9 18" 002W10 19" 002W11 E2201 20" $500.00 002SD8 15" Frame Width See FIGURE 1 and Seat Squeeze Matrix Measured frm back canes t frnt edge f uphlstery. 14" Frnt f seat sling 2" behind 002SD7 frnt edge f frame. 002SD9 002SD10 002SD11 002SD72 16" 17" 18" 19" 002SD13 E2203 20" Seat Depth $75.00 $550.00 Frame Depth 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 002FD5 14" 002FD6 15" 002FD7 16" (*) 002FD8 17" (*) 002FD9 18" (*) 002FD10 19" (*) 002FD36 20" (*) T rder any JAY cushins n-chair, please see the JAY price list. Cushin name r part number must be filled ut with desired width and depth JAY Bundled Cushin 002SL1 002SL6 002JC20 002CU1 Width: Seat Sling Standard Seat Sling Omit Seat Sling -$15.00 JAY Cushins (Optinal) Cushin Name r Part # Cushin 2" Cushin Depth: Price List $120.00 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Specificatins are subject t change withut ntice. Cpyright 2012 Sunrise Medical (US) LLC. (03.17) Quickie 2 Lite MK-100402 REV A Page 1
Figure 1 Figure 2 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 $150.00 002CF53 E1015 Frg Legs Suspensin (0-100 lbs) $425.00 002CF54 E1015 Frg Legs Suspensin (101-190 lbs) $425.00 002CF55 E1015 Frg Legs Suspensin (191-265 lbs) $425.00 Multi Psitin Single side Frg Leg 002CW1 002CW3 Caster Wheels 3" Micr 4" Lw Prfile Plyurethane 002CW31 4" Micr Lighted $70.00 002CW72 4" x 1" Aluminum Plyurethane $100.00 002CW44 4" x 1.25" Semi Pneumatic $55.00 002CW64 4" x 1.5" Aluminum Sft Rll $175.00 002CW5 5" Lw Prfile Plyurethane 002CW51 5" Micr Lighted $85.00 002CW6 002CW65 002CW7 002CW66 002CW34 002CW33 002CW35 002CW68 E2214 E2215 5" Sft Rll (Grey) NA w/ Frg Legs 5" x 1" Aluminum Plyurethane $110.00 5" x 1.5" Semi-Pneumatic $85.00 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 $185.00 $75.00 $85.00 $195.00 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 Specificatins are subject t change withut ntice. Cpyright 2012 Sunrise Medical (US) LLC. (03.17) Quickie 2 Lite MK-100402 REV A Page 2
4. REAR WHEELS / SEAT HEIGHT 13" & 13.5" NA w/ transit 002RH11 13.0" 002RH18 16.5" 002RH12 13.5" 002RH19 17.0" 002RH13 14.0" 002RH26 17.5" 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 002XH6 002XA11 Spare Li-in Pwer Pack - LITHIUM $1,795.00 002XA2 002XA4 24" Xtender Pwer Assist JWX-2 NICKEL Stainless Steel SPARE 22" Lite Spke Pneu Alum $8,695.00 $7,895.00 $8,695.00 See availability matrix. Nt applicable w/ Xtender Pwer Assist Optin. 002RW103 20" Mag Wheel 5 Spke 002RW104 22" Mag Wheel 5 Spke 002RW102 24" Mag Wheel 5 Spke 002RW90 20" Lite Spke Wheel $200.00 002RW91 22" Lite Spke Wheel $200.00 002RW92 24" Lite Spke Wheel 002RW93 25" Lite Spke Wheel 002RW94 26" Lite Spke Wheel $80.00 002AX1 002AX11 002XT6 002XT7 002XT4 002XT5 002XA10 002XA8 002XA9 002RW77 002RW78 Rear Seat Height Axle Xtender Pwer Assist (265 weight capacity) E2213 E2213 Quick Release Steel 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 LITHIUM Xtender - Other Optins Spare NiMH Pwer Pack - NICKEL Xtender Wheel Optins SPARE 22" Lite Spke Pneu Plastic Rear Wheel Type 22" Ultra Lightweight Spke Wheel Only available w/ andized handrim 24" Ultra Lightweight Spke Wheel Only available w/ andized handrim $125.00 $7,895.00 $1,395.00 SPARE 24" Lite Spke Pneu Alum SPARE 24" Lite Spke Pneu Plastic $250.00 $250.00 Rear Wheel Type (Cnt) * Omit Rear wheel will default chair cnfiguratin set up t a 24" wheel. Tplin wheels nly available t 265 lbs weight capacity. 002RW28 22" Spinergy SPOX Black $795.00 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 002RW95 24" Spinergy SPOX Black $795.00 20" All X X X X X X X X NA NA NA NA NA NA 002RW96 25" Spinergy SPOX Black $795.00 22" Ply NA NA X X X X X X X X NA NA NA NA 002RW97 26" Spinergy SPOX Black $795.00 22" Pneu NA NA NA X X X X X X X X NA NA NA 002RW32 22" Spinergy LX Black $995.00 24" Pneu NA NA NA NA X X X X X X X X NA NA 002RW98 24" Spinergy LX Black $995.00 24" All but Pneu NA NA NA NA X X X X X X X X NA NA 002RW99 25" Spinergy LX Black $995.00 25" SHOX NA NA NA NA X X X X X X X X NA NA 002RW40 26" Spinergy LX Black $995.00 25" All but SHOXNA NA NA NA NA X X X X X X X X NA 002RW50 24" Muntain $250.00 26" All NA NA NA NA NA NA X X X X X X X X 002RW107 002RW108 002RW109 002RW110 002RW49 002RT1 002RT2 002RT3 002RT39 002RT21 E2213 E2218 25" Tplin Carbn Red Spk Whl Pneumatic Airless Insert Full Ply High-Pressure Clincher Black 002RT38 E2218 SHOX Perfrmance Ply 002RT12 002HR4 002HR22 002HR25 002HR23 002HR31 002HR27 002HR28 002HR24 002HR7 002HR8 24" Tplin Carbn Yellw Spk Whl Omit Rear Wheel (Use w/22" Xtender) Rear Wheel Tire Pneumatic Knbby V-TRAK Muntain Tire Only available n 24" Muntain Rear Wheel Natural Fit - Super Grip Natural Fit LT- Standard Grip $80.00 Schwalbe Marathn Plus Evlutin $125.00 Natural Fit - Standard Grip Natural Fit - N Thumb Grip Natural Fit LT- Super Grip Natural Fit LT - N Thumb Grip The Surge LT - Oval w/griptin Strip 8 Oblique NA w/ Xtender, Only available with 24" r 26 " r Lite Spke rims. Rear Seat t Flr Height Matrix 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 002HR1 002HR30 002HR32 002HR26 24" Tplin Carbn Red Spk Whl 25" Tplin Carbn Yellw Spk Whl 002RW25 Omit Rear Wheel and Axle * 002RW111 002RT27 Omit Rear Wheel (Use w/24" Xtender) Handrim Aluminum Andized Plastic Cated -NA n every rim The Surge - Oval w/griptin Strip Q-Grip Neprene Cated Spinergy Flex Rim Available n 24" & 25" Spinergy LX wheel Omit Handrim Optin may nt be available n all wheels -$55.00 $410.00 $315.00 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 shift up r dwn by as much as 1/2". Call custmer service r nline cnfiguratr fr mre infrmatin. Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Specificatins are subject t change withut ntice. Cpyright 2012 Sunrise Medical (US) LLC. (03.17) Quickie 2 Lite MK-100402 REV A Page 3 $410.00 $395.00 $525.00 $325.00
4. REAR WHEELS / SEAT HEIGHT (cnt) Tire Pneumatic Pneumatic w/airless Insert Full Ply Tire High Pressure Clincher black Knbby V-TRAK Schwalbe Marathn Wheel SHOX Perfrm. Ply 5 Spke Mag Mag Lite Spke,26 Ultra Lt wt 24,25,26 22,24 20"= 451 mm 22" = 501 mm 24" = 540 mm 25" = 559 26" = 590 24,26,26 24,26 22,24,25,26 24 24,25 22,24 Spinergy 22,24,26 24 24,25,26 24,25 Camber 002CI1 0 00217CI 2 (default) 002CI3 4 Center f Gravity Preset 002CC2 002CC3 002CC4 002CC5 002CC6 002CC7 1.0" (default) 1.5" 2.0" 2.5" 3.0" 3.5" 5. WHEEL LOCKS Wheel Lck N Gs may exist depending n wheel size and psitin 002WL46 002WL50 002WL75 002WL64 High Munt Push High Munt Pull Erg Scissr Cmpact $110.00 $125.00 002WL24 Unilateral Wheel Lck Right $300.00 002WL23 Unilateral Wheel Lck Left $300.00 002WL10 Omit 002WL12 Wheel Lck Optin D Nt Munt Extensin Handle NA w/ erg scissr r cmpact wheel lcks 002EH7 E0961 Extensin Handle (Pair) Grade Aid Only available w/ high munt push r pull t lck wheel lcks n pneumatic r pneumatic w/ airless tire ptins $65.00 002GA1 E0974 Grade Aid $150.00 6. HANGER & FOOTREST 002H32 Swing - Away Hangers Ftplate munts with Extensin Tube using clamping hardware 002H145 002H139 002H141 60 Swing In/Out Hanger 70 Swing In/Out Hanger See Extensin matrix fr leg length range 002E1 002E2 002E5 Shrt Medium Lng Omit Hanger and Ftplate Ftrest Extensin Tubes Extensin Matrix 80 Swing In/Out Hanger Heel lp r leg strap nt included, See Ftplate Optins Sectin -$15.00 002F48 002F1 002F271 002F3 002F245 002F250 002HL1 002HL5 E0951 K0038 Platfrm Flip Up Aut Fld Angle Adj Fixed frnt frame nly Ftplate Optins Heel Lp Leg Strap Ftplates Cmpsite (14"-20"w) Aluminum Angle Adj (14"-20"w) Tubular Flip Up Fixed frnt frame nly Cmpsite Angle Adj (16"-20"w) $150.00 $185.00 $190.00 $100.00 $200.00 $30.00 $35.00 Lwer Leg Length Setting Recmmend 2" ftrest clearance t grund surface 002LO07 12.0" 002LO16 16.5" 002LO08 12.5" 002LO17 17.0" 002LO09 13.0" 002LO18 17.5" 002LO10 13.5" 002LO19 18.0" 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" Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Specificatins are subject t change withut ntice. Cpyright 2012 Sunrise Medical (US) LLC. (03.17) Quickie 2 Lite MK-100402 REV A Page 4
7. BACKREST / SEATING Clr Binding: Silver Orange Red Blue 002BU70 E2611 Backrest Tensin Adjust Ballistic 002AH1 3" Pivt Pint Setting 002BU89 E2611 Backrest Tensin Adj EXO 002AH2 4" Pivt Pint Setting Clr Binding: Silver Orange Red Blue Select desired setting 002BU71 E2611 Backrest Tensin Adj 3DX Vented -14-12 -9-7 -1 0 +4 +5 002BU82 002BU14 E2611 Jay GO Backrest Omit Back Uphlstery Back Pst Optins 002BT10 002BT84 002PH6 002PH11 002PH5 002PH2 002PH12 002PH17 See Matrix 002B1 002B5 002B9 Integral Push Handles w/8 Medium & Tall nly, NA w/ Angle Adj Back Omit Push Handles w/8 Medium & Tall nly, NA w/ Angle Adj Back Lw Backrest Height Medium Tall Back Type Standard (9"-20") Angle Adjustable Back (3" & 4") Angle Adjustable Back Setting Integral Push Handles Fld-Dwn Push Handles NA w/ standard Uphlstery and J3 Back Omit Push Handles Flding Push Handle with Ht. Adj. Back NA w/angle Adj Back $185.00 $25.00 $100.00 $225.00 002BU1 002BU88 002JB01 Backrest Uphlstery Standard Uphlstery Standard Uphlstery EXO JAY Back (Optinal) J3 Back (See J3 Order Frm) Military Service Patches (Optinal) $315.00 $320.00 $330.00 $400.00 -$15.00 NA with standard Uphlstery 002VU2 002VU4 Army Patch Air Frce Patch 002VU12 Cast Guard Patch 002VU1 002VU3 002VU5 002VU9 Marines Patch Navy Patch Purple Heart Patch 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 $15.00 $15.00 Price List Back Height Setting 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 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Specificatins are subject t change withut ntice. Cpyright 2012 Sunrise Medical (US) LLC. (03.17) Quickie 2 Lite MK-100402 REV A Page 5
8. ARMREST / SIDE GUARDS 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 (12") 002AA11 002AA29 002AA65 E0973 E0973 E0973 Padded Swing Away Height Adjustable Single Pst Hgt. Adj. Std (8.5"-13.5") Single Pst Hgt. Adj. Lw (7"-11") Flip Back Height Adj LITE (8.5"-13.5") $285.00 $285.00 002SG33 K0108 Armpad fr Height Adjustable Side Guard Plastic Standard (8.5" High) $125.00 002SG29 K0108 Plastic Lw (6.5" High) $125.00 Omit Armrest 002AA14 Omit Armrest 9. KEY OPTIONS & ACCESSORIES Anti-Tip 002AT1 E0971 Rear Anti-Tip ( w/ Xtender) $140.00 Backpack 002A1 Quickie Backpack Black $55.00 002A2 Quickie Kids Backpack Black $50.00 Seat Puch 0021A01 Seat Puch Black /Charcal $45.00 Additinal Cver & Pack Accessries 0028A01 Gel Cver Hanger/Frame $110.00 0028A02 Gel Cver Swing Away Arm $110.00 Psitining Belts 002A141 002A117 002A118 E0978 E0978 E0978 Belt 1.5" Aut Buckle w/clamps Belt 2" Aircraft Buckle w/clamps Belt 2" Aircraft Buckle Pad w/clamp $70.00 $110.00 $120.00 002A120 K0108 Psitining Belt Slide Clamps $50.00 Spke Guards Only available w/ Muntain, and Lite Spke wheels Nt available with 5 spke MAG wheels 0024A01 K0065 Quickie Black Spke Guards $115.00 0024A02 K0065 Quickie Clear Spke Guards $115.00 Miscellaneus 0028A03 Caddy $45.00 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 002C142 002C143 Candy Red Electric Blue Evergreen 002C126 002C144 Glw 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 002C108 Matte Frame Clrs Matte Black Matte Black Cherry Matte Electric Blue Matte Evergreen Matte Purple Custm Frame Clr 002C112 Desert Camuflage 002C43 002C42 Mssy Oak Camuflage Stars & Stripes Zebra (Chse abve base clr) Std with White unless abve base paint is chsen NA w/ Black Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Specificatins are subject t change withut ntice. Cpyright 2012 Sunrise Medical (US) LLC. (03.17) Quickie 2 Lite MK-100402 REV A Page 6