Fillable Parts Enquiry So we can accurately quote, please (Accident Compensation Corporation New Zealand)

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Parts Enquiry So we can accurately quote, please (Accident Compensation Corporation New Zealand)

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Country of origin: NEW-ZEALAND
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Parts Enquiry
So we can accurately quote, please complete all of the information below.
PLEASE SEND PHOTO’S – taken by you or the client
• Full photo of chair/equipment
• Photo of affected part showing critical measurements
• Photo of manufactures serial number
Company:
Contact and Telephone:
Region:
Client Name:
Chair Make and Model:
Serial Number:
Your Reference:
Funding Agent:
MOH
☐ ACC ☐ Private ☐
Please list each part separately and supply a photo
Description Quantity Photo Attached
☐
☐
☐
☐
☐
☐
NOTES:
Permobil New Zealand | 0800 115 222 | Tech.NZ@permobil.com | permobil.co.nz
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Parts Enquiry So we can accurately quote, please (Accident Compensation Corporation New Zealand)

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Completed 18 November 2021

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