Fillable F5 Corpus VS Dealer Information * Indicates a (Accident Compensation Corporation New Zealand)

Fill Online, Printable, Fillable, Blank F5 Corpus VS Dealer Information * Indicates a (Accident Compensation Corporation New Zealand) Form

Use Fill to complete blank online ACCIDENT COMPENSATION CORPORATION NEW ZEALAND pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

F5 Corpus VS Dealer Information * Indicates a (Accident Compensation Corporation New Zealand)

On average this form takes 55 minutes to complete

The F5 Corpus VS Dealer Information * Indicates a (Accident Compensation Corporation New Zealand) form is 22 pages long and contains:

  • 0 signatures
  • 257 check-boxes
  • 100 other fields

Country of origin: NEW-ZEALAND
File type: PDF

Use our library of forms to quickly fill and sign your Accident Compensation Corporation New Zealand forms online.

BROWSE ACCIDENT COMPENSATION CORPORATION NEW ZEALAND FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
PO#:
_____________________________
_
* Shipping Location:_____________________________
_
Address:
_____________________________
_
* Phone#:_____________________________
_
* Contact:_____________________________
_
* City:_____________________________
_
* Fax#:_____________________________
_
* Weight:______________________________
_
*Height:______________________________
_
A) Top of Shoulders:
______________________________
B) Chest Depth:
______________________________
C) Chest Width:
______________________________
D) Seat Depth:
______________________________
E) Top of Head:
______________________________
F) Elbow to Hand:
______________________________
G) Seat Pan to Elbow:
______________________________
H) Hip Width:
______________________________
*I) Knee to Foot:______________________________
_
Permobil New Zealand Ltd
181A McLeod Rd, Te Atatu South
Auckland 0610, New Zealand
0800 115 222
permobil.com/en-nz
* State
:
_____________________________
_
Diagnosis:
_____________________________
_
Permobil recommends that the client is evaluated by a
certified rehab specialist.
Dealer Information
Client Information
Client Measurements
Funding Source:
_____________________________
_
Prices effective: September 1, 2020
Client Age:
_____________________________
_
Company Code:______________________________
* First Name:_____________________________
_
* Indicates a Required Field
* Last Name:_____________________________
_
Email Address:
_____________________________
_
F5 Corpus VS
PERMNZ
F5 Corpus VS
Chair Model and Colors
I108400-99-0
F5 Base Corpus VS
Price Includes: FWD F5 Power Base, ComfortRide Pro Fully Independent Adjustable
Suspension, ESP (Enhanced Steering Performance), Powered Support Wheels, Tie-Down
Hardware for Strap Systems, Charger, Flat Free or Pneumatic Tires, and a Standard
Positioning Belt. Max Speed = 12kmh, Weight Capacity = 136kg, STFH = 17.5".
CHOOSE SPEED PACKAGE:
DescriptionPart Numbe
r
Set Max Speed to 12 kmh I107039-99-0
No Charge
Set Max Speed to 10 kmh I107358-99-0
No Charge
CHOOSE DRIVE TIRES:
DescriptionPart Numbe
r
Flat Free Tire 3"W x 14"T Black - Standard TreadI108414-99-0
No Charge
Designed for a smooth ride on indoor and outdoor surfaces. Includes flat free standard tread
caster wheels.
Pneumatic Tire 3"W x 14"T Black - Standard TreadI108411-99-0
No Charge
Includes flat free standard tread caster wheels.
Flat Free Tire 3"W x 14"T Black - Aggressive TreadI108413-99-0
No Charge
Includes flat free aggressive tread caster wheels.
OPTIONAL DRIVE TIRES:
DescriptionPart Numbe
r
Pneumatic/Snow Tire 3"W x 14"T Black - Aggr TreadI108412-99-0
Snow tires are designed for use in cold weather conditions. The nylon compound in these tires
remains flexible at low temperatures, but wears more easily. Therefore, the snow tires (sold as
wheel assemblies) are not recommended for year-long use and must be ordered along with
standard drive wheels. Does not include caster wheels.
CHOOSE SHROUD COLOR
:
DescriptionPart Numbe
r
F5 Color Kit - AquaI108961-99-0
No Charge
F5 Color Kit - SkyI108962-99-0
No Charge
F5 Color Kit - VioletI108963-99-0
No Charge
F5 Color Kit - FlamingoI108964-99-0
No Charge
F5 Color Kit - ChiliI108965-99-0
No Charge
F5 Color Kit - CanaryI108966-99-0
No Charge
F5 Color Kit - SpringI108967-99-0
No Charge
F5 Color Kit - ArcticI108968-99-0
No Charge
F5 Color Kit - SunsetI108969-99-0
No Charge
F5 Color Kit - MidnightI108970-99-0
No Charge
F5 Color Kit - GoldI108971-99-0
No Charge
F5 Color Kit - BronzeI108972-99-0
No Charge
F5 Color Kit - PlatinumI108973-99-0
No Charge
F5 Color Kit - Carbon FiberI108974-99-0
No Charge
F5 Color Kit - Mossy Oak Break-Up CountryI108975-99-0
No Charge
F5 Color Kit - CDG PolyI108976-99-0
No Charge
F5 Color Kit - FireballI108978-99-0
No Charge
F5 Color Kit - Water LilyI108979-99-0
No Charge
CHOOSE HUB CAP KIT:
DescriptionPart Numbe
r
Hub Cap Color:
Please write in Hub Cap Color below. Hub Cap Color will be matched to the Shroud Color if no
selection is made. __________________________________________________
Page 2 of 16
Rev 2020-1
F5 Corpus VS
Base Options
MUST CHOOSE SEAT ELEVATOR:
DescriptionPart Numbe
r
Active Height Power Adj. Seat Height - 14" TravelI107087-99-0
SET SEAT HEIGHT:
DescriptionPart Numbe
r
Set Seat Height to 17.5" I107435-99-0
No Charge
Set Seat Height at 18.5" I107433-99-0
No Charge
If ordering Power Adjustable Seat Height, 1" of elevator travel is used to set seat at 18.5".
Set Seat Height at 19.5" I107434-99-0
No Charge
If ordering Power Adjustable Seat Height, 2" of elevator travel is used to set seat at 19.5".
MUST CHOOSE BATTERIES:
DescriptionPart Numbe
r
I108999-99-0
BATTERY OPTIONS:
Permobil Batteries, MK Battery G24 Pair. Comes with Power First Charger
For maximum range. Includes Permobil VoltPro charger optimized for Permobil Batteries.
OPTIONAL ITEMS:
DescriptionPart Numbe
r
I107459-99-0
I108417-99-0
I108527-99-0
I10715
I10787
I10788
Essentials Box with Reflectors
Please Note: The total backrest angle will be limited to 150° to avoid contact between backrest
components and the Essentials Box. New design available Spring 2020!
Essentials Box with Lights
Please Note: The total backrest angle will be limited to 150° to avoid contact between backrest
components and the Essentials Box. Must also select Light Kit. New design available Spring
2020!
LED Light Kit for F5
Compact Laptop Ventilator Tray - Corpus Seat
Accommodates Pulmonetics LTV Series and similar sized Laptop Ventilators. The tray is 13"T,
adjustable in width from 8" - 13", and adjustable in depth from 2" - 6.5". Overall backrest angle
limited to 150° when mounting this ventilator tray. Custom Option. Additional drive restrictions
may apply.
Battery Tray for Laptop Ventilator Tray
Measures 11 3/8" W x 6 1/2" H x 1 5/8" D. Accomodates Pulmonetic Systems Lithium-Ion
Battery Pack, CareFusion SprintPack Battery System, or Richardson PowerTech Vent Power
Center. Custom Option.
O2 Holder for Laptop Ventilator Tray
Mounts to Left or Right Side of Laptop Vent Tray. O2 Holder is 7" Tall. Width infinitely
adjustable from 3.5" - 7". Depth infinitely adjustable from 3.75" - 5". Custom Option.
Programming Key for R-net - Permobil Version
ID51113
Joystick Options
I107778-99-0
I107829-99-0
PLEASE NOTE:
For additional input devices, refer to Alterative Drive Systems section.
Permobil Joystick Module
Designed exclusively for Permobil, this R-net color joystick features: a 2.8" color display,
control of up to 4 Bluetooth devices, Infrared control, programmable buttons and a
programmable switch jack; all in a compact, durable Aluminum housing.
3.5mm Y-Splitter Cable for PJSM/CJSM
For use with the PJSM or CJSM Mode/Profile jack. Allows 2 mechanical switches to control 4
separate functions. Requires PC Programming to assign the short hold and long hold
commands to each switch. Switches sold separately.
Page 3 of 16
Rev 2020-1
xxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
I107031-99-0
F5 Corpus VS
Joystick Options
R-net Remote Color JS w/ Lights, Heavy Duty GimbalI105700-99-0
Heavy-Duty modification enables gimbal to hold up to extreme operating forces. Reinforced
housing is attached to a standard Color LCD R-net Joystick. 3" long joystick knob has 3/4"
diameter. Not compatible with alternative joystick handles.
CHOOSE JOYSTICK HANDLE TYPE:
DescriptionPart Numbe
r
Cone Shaped Joystick Knob - StandardI10045
No Charge
Chin Cup For Joystick KnobI100960-99-0
"T" Handle For Joystick KnobI100961-99-0
"Large Ball" For Joystick KnobI100962-99-0
"Softball" For Joystick KnobI100963-99-0
"Mushroom" For Joystick KnobI100964-99-0
"Stick" For Joystick KnobI100965-99-0
1.75" Black Foam Ball For Joystick KnobI105442-99-0
Bodypoint J/S Handle 3" U-Shaped w/ Flex-ShaftI105846-99-0
Bodypoint J/S Handle 4" U-Shaped w/ Flex-ShaftI105847-99-0
Bodypoint J/S Handle Dome Shaped, RubberI105848-99-0
CHOOSE JOYSTICK MOUNT:
DescriptionPart Numbe
r
Joystick Mount Right - FixedI10664
No Charge
Joystick Mount Left - FixedI10665
No Charge
Joystick Mount Right - Swing AwayI102537-99-0
Joystick Mount Left - Swing AwayI102538-99-0
Slimline Retractable Joystick Mount - RightI108037-99-0
Slimline Retractable Joystick Mount - LeftI108038-99-0
Adjustable Height Panel BracketI11232
Provides 1.77" of vertical adjustment below the armrest and 25° of angle adjustment.
Compatible with all Permobil joystick mounts except for the M1 Fixed Joystick Mount.
Mount Standard Joystick on Corpus Back HingeI105210-99-0
Standard R-net Joystick is mounted to backrest hinge. Can be chosen instead of PN
I105408-99-0. Mount on Left: _____ Mount on Right: _____
Co-Pilot Attendant Control R-net - CorpusI105225-99-0
Attendant Control R-net I105408-99-0
R-net Bluetooth iDevice ModuleI107350-99-0
A
llows input device commands (such as joystick nudges or switch clicks) to be used to operate
an iPhone, iPad or iPod. By assigning each input to an iOS function, users can make phone
calls, send texts and emails and access applications. Kit includes a Bluetooth iDevice Module,
an R-net Bus Cable, and two mono jack cables for direct switch inputs (switches not included).
Must be ordered with a Color JSM or Omni for mode display.
R-net Bluetooth Mouse ModuleI107367-99-0
Enables mouse control through any R-net input device. It can operate the mouse on a
computer and on select Android devices (with R-net for Android app). Kit includes a Bluetooth
Mouse Module, an R-net Bus Cable, two mono jack cables for L/R click (switches not included)
and a USB BT Adapter for user's computer. Note: BT Adapter may not work with all
computers. Must be ordered with a Color JSM or Omni for mode display.
Add a second Bluetooth Mouse ModuleI107368-99-0
A
llows R-net to simultaneously pair to a second compatible computer or Android device. Each
module is accessible through a separate R-net mode. Kit includes a unique Bluetooth Mouse
Module, an R-net Bus Cable, two mono jack cables for L/R click and a USB BT Adapter.
Output Module (IOM) for R-net Control SystemI10582
This allows a user to control an external device (ex: Communication Device, ECU, Door
Opener, etc.) through the drive input (JSM, Head Array, etc.). Each module can provide up to
4
switch closures. May require specialty cable or wiring. Up to three output modules can be
installed on one wheelchair.
Page 4 of 16
Rev 2020-1
F5 Corpus VS
Seating System
POWER SEAT OPTIONS:
DescriptionPart Numbe
r
Power Tilt and Power Recline - VS SeatI11112
This item must be selected. Includes 50° Power Tilt & 180° Power Recline.
Power Standing Function - VS SeatI107029-99-0
This item must be selected. Tilt Table Stand is not available for clients over 100kg.
Seating System Options
CHOOSE SEAT FUNCTION CONTROL TYPE:
DescriptionPart Numbe
r
Seat Function Control Kit for R-netI10585
Please indicate below if you would like push buttons or toggles on the ICS Switchbox.
CHOOSE PUSH BUTTONS OR TOGGLES:
DescriptionPart Numbe
r
Push Buttons on ICS SwitchboxI102798-99-0
No Charge
Toggle Switches on ICS SwitcboxI102799-99-0
Do Not Install ICS Switchbox, Send as PartI105409-99-0
No Charge
CHOOSE MOUNTING POSITION OF ICS SWITCHBOX:
DescriptionPart Numbe
r
Mount ICS Switchbox onto R-net Joystick BracketI10626
No Charge
ICS Switchbox will be mounted to the same bracket as the R-net Joystick Module. If this item
is selected, the ICS Switchbox will swing away with the Joystick Module.
Mount ICS Switchbox onto ArmrestI104651-99-0
No Charge
Mount on Left: _____ Mount on Right: _____
Mount ICS Switchbox on BackrestI106256-99-0
Mount on Left: _____ Mount on Right: _____
OPTIONAL ITEMS:
DescriptionPart Numbe
r
I104196-99-0
I108526-99-0
I10750
I106209-99-0
I10898
No Charge
I108854-99-0
No Charge
ICS Alternative Switchbox for R-net Electronics
Seat function interface box that accommodates up to 8 momentary switches. Provides an
additional method for accessing the seat functions. 1/8" mini-mono switches not included.
Remote Stop System - AUS/NZ/EU
Consists of a 433MHz Radio Frequency (RF) handheld transmitter and an RF receiver
mounted on the wheelchair.
Memory Seat Program, Corpus w/ R-net
Legrest Movement Linked to Recline Electronically
Power Legrest will raise when Power Recline moves backward and will lower when back
moves forward. If Power Legrest is operated, Power Recline will NOT automatically reposition.
Feature works through ICS Switchbox and Driver Control.
Enable Independent Repositioning Mode
IRM allows for sequential movement of power seat functions into a posterior position (35° tilt,
115° recline, 135° legrest) and returns to upright position (5° tilt, 100° recline, 110° legrest).
This can be accessed using a standard drive control or a single switch. On the Permobil
Joystick Module, IRM is accessible through the mode/profile jack (long switch hold). Please
see the Alt Drive Accessories section for switch options.
ConnectMe Module - 4G Australia
The ConnectMe Module allows the chair to connect via the MyPermobil user application, and
in turn connects to the Fleet Management Portal for improved proactive fault detection and
asset management.'
Page 5 of 16
Rev 2020-1
F5 Corpus VS
Backrest Options
CHOOSE FIXED OR SLIDING BACKREST KIT:
DescriptionPart Numbe
r
Sliding Backrest Kit - 5" Mechanical ShearI107030-99-0
No Charge
Fixed Backrest Kit - No Mechanical ShearI105066-99-0
CHOOSE BACKREST TYPE:
DescriptionPart Numbe
r
BACKREST NOTE: I11120
No Charge
Ergo Backs include: lateral wedges, foam lumbar pads*, UT rail mounted at the top for lateral
adjustment of the headrest, and split backrest feature with height adjustment in 1" increments.
Please indicate backrest height below so that a properly sized backrest cushion can be
p
rovided. Note: Backrest heights are measured from the seat pan to the top of the backrest
shell with the backrest set at 90°. * Foam lumbar pads not included with Solid Backs.
Corpus Ergo Back - 14"W x 23" - 28"T (C3GERGBCA)I106532-99-0
Corpus Ergo Back - 16"W x 23" - 28"T (C3GERGBCA)I106533-99-0
Corpus Ergo Back - 18"W x 23" - 28"T (C3GERGBCA)I106534-99-0
Corpus Ergo Back - 20"W x 23" - 28"T (C3GERGBCA)I106535-99-0
Set Corpus Backrest at 23" _____
Set Corpus Backrest at 24" _____
Set Corpus Backrest at 25" _____
Set Corpus Backrest at 26" _____
Set Corpus Backrest at 27" _____
Set Corpus Backrest at 28" _____
CHOOSE BACKREST CUSHION:
DescriptionPart Numbe
r
Leatherette Cushion - Corpus Ergo BackI11335
No Charge
Includes Dual Density Backrest Foam.
Stretch-Air Cushion - Corpus Ergo BackI11336
No Charge
Includes Dual Density Backrest Foam with Stretch-Air breathable fabric cover.
CHOOSE ONE OF THE FOLLOWING:
DescriptionPart Numbe
r
BodiLink Premium 3" x 5" Lateral Supports - PairI109029-99-0
Must also select I109031-99-0. Includes foam wedge for additional support. Only compatible
with Corpus Ergo backrest shells.
BodiLink Premium 4" x 6" Lateral Supports - PairI109030-99-0
Must also select I109031-99-0. Includes foam wedge for additional support. Only compatible
with Corpus Ergo backrest shells.
Swing-Away Adj BodiLink Lateral Hdwr Corpus PairI109031-99-0
OPTIONAL ITEMS:
DescriptionPart Numbe
r
Direct Backrest Frame - CorpusI106072-99-0
Used to mount ROHO Agility, Jay 3, Matrx Elite, Varilite Icon and Ride Java backrests ranging
in width from 14" to 20". Slotted brackets and 1" UniTrack linkage disks provide a close,
adjustable mount. Backrest pitch can be tuned by rotating the linkage disks. Some seat depth
may be lost due to the position and orientation of the backrest.
Tailored Backrest Cushion - CorpusI10786
Sides of cushion are trimmed to provide additional clearance for lateral trunk supports. Must
also select a backrest cushion (I10659 or I10660) when ordering this custom option.
I107023-99-0
No Charge
Page 6 of 16
Rev 2020-1
Omit Backrest
Set Seat Width at 17": ____
I11231
F5 Corpus VS
Seat Sizing
CHOOSE SEAT WIDTH:
Description
Part Number
Set Seat Width at 19": ____I107024-99-0
No Charge
Set Seat Width at 21": ____I107025-99-0
No Charge
Set Seat Width at 23": ____I107026-99-0
No Charge
CHOOSE SEAT DEPTH:
DescriptionPart Numbe
r
PLEASE NOTE:
There are three seat depth kits, each providing three seat depth settings: (1) 14" - 16", (2) 17"
-
19" and (3) 20" - 22". Please select the required seat depth and the appropriate kit will be
p
rovided.
Seat Depth 14" I107013-99-0
No Charge
Seat Depth 15" I107014-99-0
No Charge
Seat Depth 16" I107015-99-0
No Charge
Seat Depth 17" I107016-99-0
No Charge
Seat Depth 18" I107017-99-0
No Charge
Seat Depth 19" I107018-99-0
No Charge
Seat Depth 20" I107019-99-0
No Charge
Seat Depth 21" I107020-99-0
No Charge
Seat Depth 22" I107021-99-0
No Charge
CHOOSE SEAT CUSHION:
DescriptionPart Numbe
r
NOTE:
See supplemental order form for ROHO seat cushion options. A Corpus II Ergonomic Seat
Cushion will be provided for select seat sizes.
Corpus Ergo Cushion - Leatherette CoverI11337
Corpus Ergo Cushion - Stretch-Air CoverI11338
Corpus Ergo Air Cushion (C3GRHOSCA)I10965
Features ROHO Dry Floatation technology. The removable ROHO cell pad provides adjustabl
e
skin protection while the contoured foam and thigh support wedges help maintain proper
p
ositioning and stability. Includes removable stretch fabric cover. Available in widths of 17", 19
"
and 21" and depths of 17", 19" and 21", as well as 17" x 23". Not Available in 21" x 17"
Incontinence Cover for Ergo CushionI11113
Made from a stretch Dartex fabric and suitable for all Ergo cushions including the Corpus Ergo
A
ir. The cover is cut to the contours of the Ergo cushion and is designed to be used as an
outer layer of protection. Cover size will be matched to cushion size. Sent as a part.
Omit Seat Cushion I105118-99-0
No Charge
Armrest Options
CHOOSE ARMBAR KIT AND MOUNTING POSITION:
Description
Part Number
I106543-99-0
No Charge
I106544-99-0
No Charge
PLEASE NOTE:
Narrow Armbar Kit can be adjusted from 15"W to 19"W between the armrest pads
without any addtional parts. Wide Armbar Kit can be adjusted from 19"W to 23"W
between the armrest pads without any additional parts. Please select both Armbar Kit
and Width Setting below.
Narrow Armbar Kit, Inf Adjustable 15"W - 19"W
Wide Armrest Kit, Inf Adjustable 19"W - 23"W
Required when selecting a 20" wide backrest.
Set the Width Between the Armrests to: _____
Must be wider than backrest width to ensure proper fit. Please round to nearest 1".
Page 7 of 16
Rev 2020-1
F5 Corpus VS
Armrest Options
CHOOSE ARMREST HEIGHT MOUNTING POSITION
:
DescriptionPart Numbe
r
Height Adjustable Armrests - NCI105069-99-0
No Charge
No charge when ordering power tilt and/or recline.
SET ARMREST HEIGHT AT:_____I11175
No Charge
Corpus VS Armrests are infinitely adjustable from 9" - 15", measured from the seat pan to the
top of the arrmrest pad. No additional parts are needed to get this full range of adjustment. In
one inch increments (ex: 9", 10", etc.), please indicate where you would like the armrests set.
CHOOSE ARMREST PAD RIGHT:
DescriptionPart Numbe
r
4"x10" Corpus Armrest Pad Right - LeatheretteI105100-99-0
No Charge
4"x13" Corpus Armrest Pad Right - LeatheretteI105104-99-0
No Charge
4"x16" Corpus Armrest Pad Right - LeatheretteI105105-99-0
No Charge
4"x18" Corpus Armrest Pad Right - LeatheretteI105999-99-0
No Charge
4"x10" Corpus Armrest Pad Right - Black FabricI107212-99-0
No Charge
4"x13" Corpus Armrest Pad Right - Black FabricI106047-99-0
No Charge
4"x16" Corpus Armrest Pad Right - Black FabricI107214-99-0
No Charge
4"x18" Corpus Armrest Pad Right - Black FabricI105995-99-0
No Charge
4"x10" Corpus Arm w/ Permobil Gel Pad - RightI107591-99-0
4"x13" Corpus Arm w/ Permobil Gel Pad - RightI107593-99-0
4"x16" Corpus Arm w/ Permobil Gel Pad - RightI107595-99-0
4"x18" Corpus HD Arm w/ Permobil Gel Pad - RightI107597-99-0
CHOOSE ARMREST PAD LEFT:
DescriptionPart Numbe
r
4"x10" Corpus Armrest Pad Left - LeatheretteI105098-99-0
No Charge
4"x13" Corpus Armrest Pad Left - LeatheretteI105102-99-0
No Charge
4"x16" Corpus Armrest Pad Left - LeatheretteI105107-99-0
No Charge
4"x18" Corpus Armrest Pad Left - LeatheretteI105998-99-0
No Charge
4"x10" Corpus Armrest Pad Left - Black FabricI107213-99-0
No Charge
4"x13" Corpus Armrest Pad Left - Black FabricI106046-99-0
No Charge
4"x16" Corpus Armrest Pad Left - Black FabricI107215-99-0
No Charge
4"x18" Corpus Armrest Pad Left - Black FabricI105994-99-0
No Charge
4"x10" Corpus Arm w/ Permobil Gel Pad - LeftI107590-99-0
4"x13" Corpus Arm w/ Permobil Gel Pad - LeftI107592-99-0
4"x16" Corpus Arm w/ Permobil Gel Pad - LeftI107594-99-0
4"x18" Corpus HD Arm w/ Permobil Gel Pad - LeftI107596-99-0
MUST CHOOSE CHEST SUPPORT AND HARDWARE
:
DescriptionPart Numbe
r
Chest Support Small - 10"W x 5.75"TI107177-99-0
Must select Fixed or Adj Removable Hardware below.
Chest Support Medium - 12"W x 5.75"TI107176-99-0
Must select Fixed or Adj Removable Hardware below.
Chest Support Large - 14"W x 5.75"TI107175-99-0
Must select Fixed or Adj Removable Hardware below.
Fixed Chest Support HardwareI107174-99-0
No Charge
Adj Removable Chest Support HardwareI107203-99-0
No Charge
OPTIONAL ITEMS:
DescriptionPart Numbe
r
Armrest Pouch - Right I107339-99-0
Armrest Pouch - Left I107338-99-0
Page 8 of 16
Rev 2020-1
F5 Corpus VS
Armrest Options
OPTIONAL ITEMS:
DescriptionPart Numbe
r
UT Armrest Side Support - Right OuterI107840-99-0
Includes 2"T x 6.5"W tapered pad.
UT Armrest Side Support - Left OuterI107863-99-0
Includes 2"T x 6.5"W tapered pad.
UT Armrest Side Support - Right InnerI107864-99-0
Includes 2"T x 6.5"W tapered pad. May require an increase to the width between the armrests
to ensure armrests will flip-up.
UT Armrest Side Support - Left InnerI107865-99-0
Includes 2"T x 6.5"W tapered pad. May require an increase to the width between the armrests
to ensure armrests will flip-up.
UT Elbow Support - RightI107839-99-0
Must also select PN I10881.
UT Elbow Support - LeftI107838-99-0
Must also select PN I10882.
Adjustable Elbow Support Hardware - RightI10881
Adjustable Elbow Support Hardware - LeftI10882
Legrest Options
CORPUS VS LEGREST AND KNEE SUPPORT:
DescriptionPart Numbe
r
Corpus VS Power Legrest Elevation - 180°I107760-99-0
Includes power articulation.
Corpus VS Stand and Drive PackageI106965-99-0
Includes Powered Support Wheel, which are required for safe operation of the chair for both
the stand and stand and drive operation.
Knee Support - Corpus VS I107038-99-0
Select when ordering Corpus VS Legrest. Must also select I11129.
Adj Removable Knee Support Hardware (1 Each)I11129
CHOOSE FOOTPLATE STYLE:
DescriptionPart Numbe
r
No Charge1pc Corpus VS Footplate - 9"D x 16.5"W
2pc Wide Corpus VS Footplates - 9"D x 7.5"W
2pc Narrow Corpus VS Footplates - 9"D x 6"W
I106969-99-0
I106971-99-0
I106967-99-0
FOOTPLATE HEIGHT POSITION:
DescriptionPart Numbe
r
SET FOOTPLATE HEIGHT AT:____
This is measured from the SEAT PAN to the top of the FOOTPLATE, when the legrest
assembly is at 90°. DO NOT INCLUDE CUSHION THICKNESS IN YOUR MEASUREMENT.
In one inch increments, please indicate desired footplate height. NOTE: Corpus footplate
height range is 6"-17" and Corpus VS height range is 9"-17". Height may need to be reduced
for shipping. Calf Pads are not available at heights less than 9".
OPTIONAL ITEMS:
DescriptionPart Numbe
r
VS Calf Support Kit (J) w Mesh Cover & Adj HardwareI107211-99-0
No Charge
5"W x 6.5"T Pad. Compatible with footplate heights of 10" - 18".
VS Calf Support Kit (A) w Mesh Cover & Adj HardwareI106190-99-0
No Charge
5.5"W x 6"T Pad. Compatible with footplate heights of 10" - 18".
Page 9 of 16
Rev 2020-1
F5 Corpus VS
Legrest Options
OPTIONAL ITEMS:
DescriptionPart Numbe
r
VS Calf Support Kit (H) w Mesh Cover & Adj HardwareI106188-99-0
7"W x 7"T Curved Pad. Compatible with footplate heights of 11" - 18".
VS Calf Support Kit (D) w Mesh Cover & Adj HardwareI106186-99-0
8"W x 8"T Pad. Compatible with footplate heights of 12" - 18".
Stealth Gel Pads - Narrow Footplates (Pair)I106530-99-0
Stealth Gel Pads - Wide Footplates (Pair)I106225-99-0
Accessories
MUST CHOOSE POSITIONING BELT:
DescriptionPart Number
NOTE: See supplemental order form for more Bodypoint options.
I104518-99-0
No Charge
CHOOSE ONE OF THE FOLLOWING:
Part Number
No Charge
I107470-99-0
I107469-99-0
I107468-99-0
I107480-99-0
I107481-99-0
I108721-99-0
I11305
I11306
I11307
I11308
I11276
I106331-99-0
I10552
I107499-99-0
Description
Permobil 7"W Headrest w/ Link Hardware - Must also select I107480-99-0 or I107481-99-0.
Permobil 10"W Headrest w/ Link Hardware - Must also select I107480-99-0 or I107481-99-0.
Permobil 14"W Headrest w/ Link Hardware - Must also select I107480-99-0 or I107481-99-0.
Adj/Removable Headrest Link Hardware - Standard
Adj/Removable Headrest Link Hardware - Extended - Includes an additional 3" link to
extend headrest pad range
Adj/Removable BodiLink Headrest Hardware Max8 - Must be selected when ordering any of the
Swing Away Chin Boom assemblies.
Swing Away Egg Switch Assembly
Mount on Upper Left:____ Mount on Upper Right:_____
Swing Away Microlight Assembly
Mount on Upper Left:____ Mount on Upper Right:_____
Swing Away Facial Pad Assembly 4"L x 2"T
Mount on Upper Left:____ Mount on Upper Right:_____
Swing Away Facial Pad Assembly 6"L x 2"T
Mount on Upper Left:____ Mount on Upper Right:_____
Provide Headrest Receiver for AGILITY Backrest
Select for AGILITY backs and third party backs ordered off chair.
Permobil 10"W Headrest, Leatherette
Not available with ROHO AGILITY Back Systems. Must also select PN I10552.
Adj/Removable Headrest Hardware
Universal Headrest Adapter
Please Note: Recline is limited to 160° or less (depending on backrest height) when ordering a
Universal Headrest Adapter on a 23" or 24" tall Corpus backrest.
OPTIONAL ITEMS:
DescriptionPart Number
BodiLink Premium LPTS Pad (B), Stretch-Air - PairI109040-99-0
4.5"W x 3.5"T Pad w/additional foam insert and Stretch-Air cover. Must also select BodiLink
LPTS Mounting Hardware.
BodiLink Premium LPTS Pad (A), Stretch-Air - PairI109043-99-0
6"W x 5.5"T Pad w/additional foam insert and Stretch-Air cover. Must also select BodiLink
LPTS Mounting Hardware.
Page 10 of 16
Rev 2020-1
Bodypoint Non-Padd
ed Hip Belt - Medium
F5 Corpus VS
Accessories
OPTIONAL ITEMS:
DescriptionPart Numbe
r
BodiLink Premium LPTS Pad (C), Stretch-Air - PairI109041-99-0
8"W x 3.5"T Pad w/additional foam insert and Stretch-Air cover. Must also select BodiLink
LPTS Mounting Hardware.
BodiLink Premium LPTS Pad (G), Stretch-Air - PairI109042-99-0
12"W x 3.5"T Pad w/additional foam insert and Stretch-Air cover. Must also select BodiLink
LPTS Mounting Hardware.
Adj/Removable BodiLink LTPS Hdwr Med Corpus PairI109044-99-0
Medium TT Power Mount hardware can be extended upward to clear cushions of 3-5.5" thick.
Adj/Removable Lateral Thigh/Hip Hardware - PairI109194-99-0
Transfer Handles, Corpus SeatI105260-99-0
Push Handles, Corpus SeatI105292-99-0
RAM Self-Leveling Cup HolderI106210-99-0
RAM X-Grip Phone Holder I106806-99-0
RAM X-Grip 10" Tablet Holder w/Swing Away MountI107100-99-0
Compatible with most 10" screen tablets with or without a protective case. Includes adjustable
swing away mount (I103476-99-0). Note: Customization may be required if ordered along with
an Omni.
USB Charger I107222-99-0
Provides up to 1.5A (at 5V) to charge most smartphones and tablets. The charger features an
isolated circuit design for improved safety; and by pulling power from the ICS, prevents battery
drainage when the chair is powered off. Includes mounting hardware and ICS connector. Keep
in mind charger may need to be relocated with some configurations. Mount on left armrest:
_
____ Mount on right armrest: _____
Medical Necessities Bag HooksI105805-99-0
Please Note: Recline is limited to 165° or less (depending on backrest height) when ordering
with 23" or 24" tall Ergo backrest. Custom required if ordered with a ROHO AGILITY backrest.
May ship as a part at shorter backrest heights.
Medical Necessities Bag I102059-99-0
Includes hardware to attach bag to backrest. Please Note: Recline is limited to 165° or less
(depending on backrest height) when ordering with a 23" or 24" tall Ergo backrest. Custom
required if ordered with a ROHO AGILITY backrest.
Small Angle Adjustable TrayI10843
Must also select PN I10556.
Mount on Left: _____ Mount on Right: _____
Adj Removable - Tray Hardware (1 Each)I10556
Permobil Adjustable Tray - 11"WI108231-99-0
Permobil Adjustable Tray - 13"WI108230-99-0
Permobil Adjustable Tray - 15"WI108228-99-0
Permobil Adjustable Tray - 17"WI108227-99-0
Permobil Adjustable Tray - 19"WI108229-99-0
Permobil Tray Hardware Right Side AdjustableI108232-99-0
Permobil Tray Hardware Left Side AdjustableI108233-99-0
Oxygen Holder, Corpus I105224-99-0
Crutch Holder, Corpus I105223-99-0
Alternative Drive Systems
A
LTERNATIVE PROPORTIONAL JOYSTICK SYSTEMS:
DescriptionPart Numbe
r
Mini-Joystick for Omni - (9-pin connector)I10751
Operating Force = 13 g Neutral to Full Deflection = 5mm
Page 11 of 16
Rev 2020-1
F5 Corpus VS
Alternative Drive Systems
A
LTERNATIVE PROPORTIONAL JOYSTICK SYSTEMS:
DescriptionPart Numbe
r
Compact Joystick for Omni - (9-pin connector)I103893-99-0
Operating Force = 220 g Neutral to Full Deflection = 28mm Joystick includes two 3.5mm
mono jacks for Mode and On/Off. Includes Standard Joystick Knob and 1.75" (42mm) Foam
Ball Knob.
Compact Joystick LITE for Omni - (9-pin connector)I103894-99-0
Operating Force = 50 g Neutral to Full Deflection = 17mm Joystick includes two 3.5mm mono
j
acks for Mode and On/Off. Includes Standard Joystick Knob and 1.75" (42mm) Foam Ball
Knob.
A
LT PROPORTIONAL JOYSTICK MOUNTING HARDWARE:
DescriptionPart Numbe
r
NOTE:
Please see the PERMOfix Mounting Solutions, within the Alt Drive Accessories section, for
additional mounting options. The Swing Away Chin Boom Assemblies are Compatible with
Permobil Headrests I107470-99-0, I107469-99-0 or I107468-99-0 and must be selected with
I108721-99-0.
Swing Away Chin Boom Assm for Compact Lite - LeftI107946-99-0
Swing Away Chin Boom Assm for Compact Lite - RightI107948-99-0
Swing Away Chin Boom Assm for Mini Joystick - LeftI107857-99-0
Swing Away Chin Boom Assm for Mini Joystick - RightI107947-99-0
Alt. JS Swing Away Mount Kit - ArmrestI104690-99-0
Mount in front of Left Arm: _____ Mount in front of Right Arm: _____
Alt JS/Omni Combo Swing Away Mount Kit - ArmrestI107135-99-0
Used to mount Omni and Alternative Proportional Joystick to the same armrest. Includes
Swing Away Omni/Tablet Mount, with a longer mounting rod, two PERMOfix modules, one 3"
rod and one 4" rod.
Mount in front of Left Arm: _____ Mount in front of Right Arm:_____
Alt. JS Adjustable Mount Kit - Chin BoomI104143-99-0
Swing-Away / Removable Chin Boom mounted on right of backrest shell. Custom charge may
be applied if ordering lower backrest heights.
Haims Harness for Chin Control Mount, LargeI10752
For neck width up to 19cm.
Haims Harness for Chin Control Mount, SmallI10753
For neck width up to 14cm.
A
LT PROPORTIONAL JOYSTICK ACCESSORIES:
DescriptionPart Numbe
r
I104904-99-0
Dual Switches for Compact Joystick - Fixed Mount
Includes two pushbutton switches mounted on rigid arms. Switches set-up for Mode & On/
Off function. Switch operation force = 130 g
Mount at front of Joystick: _____ Mount at rear of Joystick: _____
Mount at left of Joystick: _____ Mount at right of Joystick: _____
Dual Switches for Compact Joystick - Gooseneck MntI104641-99-0
Includes two pushbutton switches mounted on adjustable gooseneck arms. Switches are
p
ositioned on Left and Right sides of Compact Joystick. Switches set-up for Mode & On/Off
function. Switch operation force = 130 g
SIP & PUFF SYSTEMS:
DescriptionPart Numbe
r
Sip & Puff System for OmniI10573
Requires Omni Control Module. Includes breath tube kit.
Sip & Puff System with Fiber Optic Opti-StopI10574
Requires Omni Control Module. Includes breath tube kit.
Sip & Puff Kit for Total Control Head ArrayI106807-99-0
For use with Total Control Head Array. Requires Omni Control Module. Includes breath tube
kit.
Page 12 of 16
Rev 2020-1
F5 Corpus VS
Alternative Drive Systems
SIP & PUFF SYSTEMS:
DescriptionPart Numbe
r
Adjustable Mounting Hrdw - Sip & PuffI10762
Required when selecting PN I10573, I10574 or I106807-99-0.
Total Control Head Array
CONFIGURE HEAD ARRAY:
DescriptionPart Numbe
r
Permobil Head Array - 3-Switch SystemI106805-99-0
Features an occipital pad sensor and two stainless steel arms configured with proximity
sensors. The arms are mounted to the upper attachment points on the head array. Longer
arms are also included to extend the sensor adjustment range. ESP recommended. Choose
Omni Control Module separately.
Program Head Array as a 5-Switch SystemI11072
No Charge
Select additional arms/sensors below and indicate the intended use of each sensor in the
Notes & Comments section. Choose Omni Control Module separately.
CHOOSE OCCIPITAL PAD SIZE (REQUIRED):
Small Occipital Pad for Head Array - 4.25"W x 3"HI105920-99-0
No Charge
Large Occipital Pad for Head Array - 6"W x 4"HI105921-99-0
No Charge
CHOOSE OCCIPITAL PAD MOUNT (REQUIRED):
Fixed Mount for Occipital Pad - Head ArrayI10847
No Charge
Adj. Swivel Mount for Head Array Occipital PadI105936-99-0
Enables Occipital Pad to be angled up/down and left/right independent of the lateral arms.
CHOOSE HEAD ARRAY MOUNT HARDWARE (REQUIRED):
Stealth TWB480 Backrest Mounting Hdwr with LinksI105927-99-0
Please select the length of the vertical stem below:
Standard length (10"): _____ Short length (6"): _____
Stealth TWB480 Backrest Mtng Hdwr with FlipbackI105941-99-0
Stealth HMO475 Backr Mtng Hdwr w 17mm BallI105925-99-0
SELECT ADDITIONAL LEFT ARM PACKAGE (OPTIONAL):
Add Left Lateral Arm w Proximity SensorI10976
Choose Lateral Arm Adjustment Range:
Short (5.5" - 10"): ______ Long (5.5" - 14"): ______
Add Left Lateral Arm w Egg SwitchI10977
Choose Lateral Arm Adjustment Range:
Short (5.5" - 10"): ______ Long (5.5" - 14"): ______
Add Left Lateral Arm w Pad (No Sensor or Switch)I10978
Choose Lateral Arm Adjustment Range:
Short (5.5" - 10"): ______ Long (5.5" - 14"): ______
SELECT ADDITIONAL RIGHT ARM PACKAGE (OPTIONAL):
Add Right Lateral Arm w Proximity SensorI10979
Choose Lateral Arm Adjustment Range:
Short (5.5" - 10"): ______ Long (5.5" - 14"): ______
Add Right Lateral Arm w Egg SwitchI10980
Choose Lateral Arm Adjustment Range:
Short (5.5" - 10"): ______ Long (5.5" - 14"): ______
Add Right Lateral Arm w Pad (No Sensor or Switch)I10981
Choose Lateral Arm Adjustment Range:
Short (5.5" - 10"): ______ Long (5.5" - 14"): ______
Page 13 of 16
Rev 2020-1
F5 Corpus VS
Alt Drive Systems Setup
CHOOSE OMNI
(
REQUIRED
)
:
DescriptionPart Numbe
r
Omni2 Control Module for R-net - CorpusI108500-99-0
Two-section design features 3.5" VGA high resolution display, USB charger port, built in IR
control and integrated Bluetooth technology for control of up to 4 Bluetooth devices. Must also
select mounting hardware below. Please specify which type of alternative drive input device
you will be using. Input Device:______________________________
Adjustable Swing-Away Hardware - Omni/TabletI103476-99-0
Mount in front of Left Arm: _____ Mount in front of Right Arm: _____
CHOOSE MOUNTING POSITION OF SEAT CONTROL SWITCHBOX
:
DescriptionPart Numbe
r
Mount Seat Control Switchbox on BackrestI10080
No Charge
Alt Drive Accessories
PERMOFIX MOUNTING SOLUTIONS:
DescriptionPart Numbe
r
PERMOfix UniTrack Fixed Mount KitI106655-99-0
Includes two base joints, two 4" rods and one 8" rod.
PERMOfix UniTrack Removable Mount KitI106656-99-0
Includes quick release mount and thigh support hardware, two base joints and three different
length rods.
PERMOfix UniTrack Swing Away Mount KitI106657-99-0
Includes PERMOfix Swing Away module, two base joints, one 2" rod and one 4" rod.
Proximity Sensor + Swivel Assm - Not MountedI105907-99-0
Only available with the Total Control Head Array. Swivel assembly allows sensor to be
mounted with PERMOfix or directly to lateral arm of Total Control Head Array. Since Proximity
Sensors require power, they CANNOT be used as On/Off switches.
Egg Switch + Swivel Mount Assm - Not MountedI105919-99-0
Swivel assembly allows switch to be mounted with PERMOfix or directly to lateral arm of Total
Control Head Array.
Solid Lateral Pad+Swivel Joint - Not MountedI105912-99-0
Swivel assembly allows pad to be mounted with PERMOfix or directly to lateral arm of Total
Control Head Array.
Oval Plate + Swivel Assm - No Switch - Not MountedI106675-99-0
Blank plate provides mounting option for Micro Lite, Buddy Button or other switch options.
Swivel assembly allows pad to be mounted with PERMOfix or directly to lateral arm of Total
Control Head Array.
OPTIONAL ITEMS:
DescriptionPart Numbe
r
Microlight Switch Qty:____I101769-99-0
Buddy Button Qty:____I101767-99-0
Egg Switch Black Qty: _____I106293-99-0
Mini Cup Switch Qty:____I101771-99-0
Proximity Switch Qty:____I107500-99-0
Mini Joyswitch 5 Switch OC for Omni - (9-pin)I107495-99-0
Dome Switch, Backrest Mnt w Gooseneck Qty: _____I10772
Mount on Left: _____ Mount on Right: _____
Mounts at top of backrest shell. Custom charge may be applied if ordering with short backrest
heights. Kit Includes: One PERMOfix joint with Flat Plate, two PERMOfix joints with 45° swivel
adjustment, one 150mm rod, one 200mm rod and one 225mm gooseneck switch with 1.2m
cable and mounting clamp.
Page 14 of 16
Rev 2020-1
F5 Corpus VS
Alt Drive Accessories
OPTIONAL ITEMS:
DescriptionPart Numbe
r
Dome Switch, Backrest Swg Awy Mnt w Gsneck Qty:____I10846
Mount on Left: _____ Mount on Right: _____
w 90° Swing-Away Function. Mounts at top of back. Custom charge applies if ordered with
short back. Kit Includes: One PERMOfix joint with Flat Plate, one PERMOfix joint with 45°
swivel adjustment, two 6" rods, one 90° Swing-Away joint, one 9"
3.5mm Ext. Cable for Sensor/Switch, 0.3m LongI105935-99-0
3.5mm Ext. Cable for Sensor/Switch, 1m LongI105931-99-0
3.5mm Ext. Cable for Sensor/Switch, 2m LongI105932-99-0
3.5mm Ext. Cable for Sensor/Switch, 3m LongI105933-99-0
3.5mm Y-splitter Cable for Sensor/SwitchI105934-99-0
A
llows two Proximity Sensors/Mechanical Switches to connect to the same direction jack.
Page 15 of 16
Rev 2020-1
Chair Order Policy:
You are highly encouraged to contact Permobil Sales with ANY questions regarding proper completion of our order forms. The order cannot be processed
without the following:
-A client name or code, the client’s measurements, the client’s weight
-The order form must also be signed by a person authorized by your company to acknowledge the items selected. Permobil is not responsible for
configuration or size discrepancies resulting from
customer errors on the order form.
-Order confirmations will be provided by Permobil summarizing the items selected. Please review this carefully.
-Once the order is shipped, any changes are subject to the returns policy and may be prohibited.
Order Acknowledgement:
I, _________________________, am an agent of the medical equipment provider named on this order form and I have the authority to contract for the
purchase of powered wheelchairs and related parts on behalf of said provider. I acknowledge that I have reviewed this order and that it is complete and
accurate to the best of my knowledge. I further acknowledge that any changes to this order after submission of this order form are subject to the returns policy
and may carry additional charges.
Signed:
Printed Name:
Title:
Date:
NOTE: All specifications and prices are subject to change without notice. Please note that prices displayed are only valid if ordered with the wheelchair. Any
parts ordered for service or future alterations will carry different pricing and warranty.
Page 16 of 16
Rev 2020-1
ADDTIONAL ORDER INSTRUCTIONS
Please ensure an MK battery and Power First charger are supplied. (I107031-99-0 and I106583-99-0)
DO NOT SUPPLY THE PERMOBIL G24 BATTERY AND VOLTPRO BATTERY.
LAPSTACKER
Add an Adaptdefy LapStacker Set. There is only one configuration for Permobil Powerchairs. Complete the LapStacker order form.
CHEST BELT OPTIONS
I105840-99-0
I105839-99-0
I105850-99-0
Bodypoint Monoflex Medium Chest Support
Bodypoint Monoflex Large Chest Support
Bodypoint Monoflex X-Large Chest Support
GENERAL COMMENTS
F5 Corpus VS
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

F5 Corpus VS Dealer Information * Indicates a (Accident Compensation Corporation New Zealand)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 22 December 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document