Order form - PROACTIV GmbH

Im Hofstätt 11D- 72359 DotternhausenTel +49 (0)7427 9480-0Fax +49 (0)7427 9480-7025E-mail info@proactiv-gmbh.dewww.proactiv-gmbh.com Quotation date: SPEEDY F4Approved up to 120 kg user load capacity9012100000 € 2,680.00 Order date:according to GTC PRO ACTIV GmbHMedical suppliers / Company address:Cust. no.:Name:Street:Postcode, city:Tel.:Fax:E-mail:Contact:Invoice address: same as company addressInvoice address: other (see below)Cust. no.:Name:Street:Postcode, city:Tel.:Fax:E-mail:Contact:Shipping address:same as company address other (see below)Name:Street:Postcode, city:Customer name / commission:Name:Street:Postcode, city:Tel.:Fax:E-mail:Date of birth:Payingorganisation:Indication:- 1 - 16/05/2014 / The prices are plus statutory value-added tax and shipping costs = Included in the basic price = Position selectedSpeedy F4 Rev. 02

Basic sizeBody size:Körpergröße:Body size:Gewicht: Weight:__________ cm cm__________ kg kgULUnterschenkellänge:Lower leg length:__________ cm cm(anatomisches (anatomic dimension: Maß: Kniekehle hollow of bis the Fußsohle) knee to the foot sole)Wheel chair dimensions:Seat width SB 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46Seat depth STBack height RHLower leg length USLSeat height back SHhShort frameLong frame 36 37 38 39 40 41 42 43 44 40 41 42 43 45 46 47 48 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 35 36 37 38 39 40 41 42 43 44 45 46 47Seat height front SHv 44 45 46 47 48 49 50 51 52 53 54Tipping point KP 2 3 4 5 6 7 8,5 9 10 11 12 13(front side rear tube to axis middle drive wheel)Please cross on the appropriate dimension (all dimensions are specified in cm).Underlined values are standard settings.The values SHh and SHv may deviate from the specified values depending on thewheel size and wheel camber! Special dimensions possible upon request.- 2 - 16/05/2014 / The prices are plus statutory value-added tax and shipping costs = Included in the basic price = Position selectedSpeedy F4 Rev. 02

Frame colour - One-colour designInformation on current colour designs and example images under:www.proactiv-gmbh.de/farben.phpWhite RAL 9016 gloss 9000100170-023 Brilliant silver gloss 9000100170-011Anthracite RAL 7016 gloss 9000100170-001 Black RAL 9005 gloss 9000100170-003 Deep black, silver effect gloss 9000100170-007Pure orange RAL 2004gloss 9000100170-022Fire Red gloss 9000100170-018 Pink magenta RAL 4010 gloss 9000100170-037 Light cyan gloss 9000100170-042 Sky blue gloss 9000100170-017Brilliant bluegloss 9000100170-002Pastel blue RAL 5024 gloss 9000100170-036 Apple green gloss 9000100170-014 Lemon green gloss 9000100170-005 Colour - Attachment partsDrive wheel Aluminiumrim and hubmatt 9000100170-123 € 32.00matt 9000100170-101 € 32.00matt 9000100170-019 € 32.00matt 9000100170-118 € 32.00matt 9000100170-137 € 32.00matt 9000100170-142 € 32.00matt 9000100170-136 € 32.00matt 9000100170-114 € 32.00matt 9000100170-105 € 32.00Caster fork andbearing blocksilver 9000100171-011 9000100173-011black 9000100171-003 9000100173-003If no details have been made, the attachment parts are mounted in black.Attachment parts colour design according to customerdesires:Drive wheel 1Aluminium rim and5" Aluminium rim 23 spoke designhubOrangeRAL 2004 € 139.30 19000100171-022whiteRAL 9016 € 139.30 19000100171-023in frame € 169.30 1colour9000100171-999 € 198.30 1Selectionfrom singlecolour designdeviatingfrom theframe colour € 29.50 29000100174-022 € 29.50 29000100174-023 € 49.50 29000100174-999 € 58.50 29000100174-998Please enter the last 3 digits of the desired colour(single colour design):9000100171-9989000100170-9000100170-Note: Attachment parts not possible in design colours1 Only in combination with aluminium rim drive wheel9000203000-90002033002 Only in combination with caster wheel 5" Aluminium rim 3-spoke designsmooth running 9000501200 or 5" Aluminium rim 3-spoke design goodshock absorption 9000501210Frame colour - Two colour designsInformation on current colour designs and example images under:www.proactiv-gmbh.de/farben.phpNote: With two-colour design, according to both colours of thegloss level of the design colour. Two-colour designcomprising onebasic colour (onthe back of the frame)and one designcolour (on thefront of the frame)€ 198.00Please select from the following colours:Base colours(on the back frame): White9000100170-200 Silver9000100170-201 Anthracite9000100170-202 Black9000100170-203 Light Cyan9000100170-204Design colours(on the front frame)Lemon green gloss 9000100170-250 matt 9000100170-251Blue (dark blue) gloss 9000100170-252Chilli gloss 9000100170-253 matt 9000100170-254Pure orange gloss 9000100170-255 matt 9000100170-256CappuccinoSpecial colour requests(frame or attachment parts)Frame colour single procurementFrame from RAL range of coloursSurface coating: gloss matt 9000100170-100 € 305.00Colour details with RAL number gloss 9000100170-257 matt 9000100170-258- 3 - 13/05/2014 / The prices are plus statutory value-added tax and shipping costs = Included in the basic price = Position selectedColours Rev. 00

FramesNote: Footrest area with V-shape x=SB (0.25 x USL + 6 cm)Straight front end 9012100010Knee angle 105°BackrestFolding backrest90124000107-way inclination adjustmentwith integrated aluminium side partsStraight front end9012100012 € 123.50Knee angle 95°Min. 4 cm seat slope andmax. caster wheel size 5"Front end V-shapeBack equipmentAdaptable back with back padding 9012802010Colour: blackEquipment with back cross bar9012100020 € 181.90Knee angle 95°from SB 33 cmFront end V-shape9012100023 € 291.90Knee angle 105°from SB 33 cmCustom made seat width dimension47 - 50cm9012100060 € 182.50with frame reinforcementDelivery time, approx. 4 to 5 weeks; with individualcustomer production, the delivery time extends.Push handlesAluminium push handles fixed inback tube9012401050 € 92.40from RH 23 cmSafety push handles withcontinuous height adjustment9012401060 € 155.60Mount in the back tubefrom RH 30 cm with belt coverfrom RH 43 cm with back shellSafety push handles backpositionedlength 45 cm9012401075 € 264.30continuous height adjustment,Safety push handle holder mounted on theback cross bar,Up to SB 42 cm or a body weight of 95 kg,not in combination with the armrest!Raised back + 3 - 5 cm9012802100 € 110.00(for the nominal back height dimension)Only in combination withcontinuous height adjustment Art no.9016401060!Equipment without back upholsteryand back padding or back system9000802011 € - 50.00Equipment with back cross barFurther back systems e.g.ergonomic back shellsee separate dimension sheet:"PRO ACTIV seat and backsystems"Seat upholsteryBody Contour 9012801025Open belt system9012801010 € 53.90Equipment without seat upholstery 9012801012Push handles, horizontally screwedin back tube9012401076 € 166.10can be unscrewed- 4 - 16/05/2014 / The prices are plus statutory value-added tax and shipping costs = Included in the basic price = Position selectedSpeedy F4 Rev. 02

Seat cushion"Standard" seat cushionHeight: 3 cm9000805180-003 € 81.10Height: 4cm9000805180-004Height: 6cm9000805180-006Cover: black orange carbon blackSeat cushion is existingBrand / Type__________________Cushion height______________________Further seat cushions e.g. "Anti-Decubitus" see separate dimensionsheet: "PRO ACTIV Seat and backsystems"Clothing guardAluminium clothing guardremovable via lock functionAdjustable following wheel archOnly in combination with folding backrest!anthracite, matt9012403210 € 172.20in frame colour(basic colour withtwo-colour design)9012403211in design colour(only possible withframes in twocolourdesign)9012403212Armrests€ 222.20€ 252.2025 cm long arm padding mounted onthe clothing guard9012403150 € 255.80Upper arm padding edge depending on theclothing guard setting mounted approx.20 cm to 24 cm above the seat tube.Only in combination with aluminium clothingguard!ArmrestsFolding up, removable9000403141 € 244.00with arm padding 25 cm longPositioning: upper arm padding edgeapprox. 25cm to 31 cm above the seat tube,adjustable in 1.5 cm stepsNot possible in combination with safety pushhandles back-positioned, Art. no.:9012401075!Wheel camber*Total width with tight-mounted hand rim1° drive wheel camber 9012202010Total width = approx. SB + 20 cm*4° drive wheel camber 9012202030Total width = approx. SB + 26 cm*6° drive wheel camber 9012202040Total width = approx. SB + 30 cm*E-adaptionsPreparation for "e-motion" mounting9012201200 € 212.90Equipment: e-motion torque support,1/2" axle and socket length 50.8 mm (2")Alber recommends that anti-tipping supportsare installed in pairs for wheelchairequipment with e-motion. Under theselection "Adaptation", please select theequipment 9016300100-001 and9016300100-002!Preparation for "e-fix" mounting9012201210 € 212.90Equipment: 1/2" axle,socket length 50.8 mm (2") and e-fix torquesupport.Alber recommends that anti-tipping supportsare installed in pairs for wheelchairequipment with e-fix. Under "Adaptation",please select the equipment e-fix Art.-No.:9016300105!Please order anti-tipping support e-fix with"Standard fork" direct from Alber.Wheelchair delivery to Ulrich Alber GmbH Specialist dealerBrake systemBrake system push to lockStandard brake handle 9012701010-001Brake system push to lockLong brake handle 9012701010-002Brake system push to lockLow brake handle 9012701010-003- 5 - 16/05/2014 / The prices are plus statutory value-added tax and shipping costs = Included in the basic price = Position selectedSpeedy F4 Rev. 02

Brake handle to Flip-down9012706008 € 112.10Length: 9cmFootplate side stop9012610100 € 41.80adjustableOnly in combination with rubber coatedfootplate!AdaptationsScissor brake9012706010 € 194.50Assembly on the lower frame tubeFootrestContinuous footrest 9012601010with tubular resting bracketheight adjustable +/- 3 cmfor KW 95° from USL 34cmfor KW 105° from USL 39 cmFor equipment of the foot bracket with"Rubber coated footplate", please selectunder "Footrest accessories".Footrest folding up to one side9012601300 € 120.60with continuous tubular resting bracket,height adjustable +/- 3 cm,can be swung away,cannot be removedfor KW 95° from USL 37cmfor KW 105° from USL 42cmwith V-shape from SB 40cmFor equipment of the foot bracket with"Rubber coated footplate ", please selectunder "Footrest accessories".Footrest folding back to the rear9012602010 € 201.50with continuous tubular resting bracket and20 mm operating leverfor KW 95° from USL 38cmfor KW 105° from USL 42cmwith V-shape from SB 33 cmwith V-shape from SB 38 cmfrom 20 cmFor equipment of the foot bracket with"Rubber coated footplate ", please selectunder "Footrest accessories".Footrest accessoriesRubber coated footplate9012610000 € 89.00bolted, angle-adjustableDepth: 14cmIn combination with tubular bracket Art.-no.9012601010, 9012601300 or 9012602010!Anti-tipping supportright side9012300100-001left side9012300100-002€ 119.60€ 119.60with tension spring and universal adapterpivotable(for optimum pivoting behaviour, theseat slope should be >3 cm)Transit wheels9012301100 € 233.70with universal adapter, removable(not in combination with anti-tipping support)Tilting clampright side9012302100-001 € 100.20Left side9012302100-002€ 100.20with universal adapter and Quick pin(not in combination with anti-tipping support,right side or left side)Caster wheelsAll caster wheels (except pneumatic tyres) are puncture-proof!4" Caster wheel "Standard" 9000501010-004(82A), puncture-proof5" Caster wheel "Standard" 9000501010-005(82A), puncture-proof6" Caster wheel "Standard" 9000501010-006(82A), puncture-proof5" Caster wheel "2 components"9000501030 € 39.70puncture-proof6" Caster wheel "Pneumatic tyre"9000501050 € 39.70- 6 - 16/05/2014 / The prices are plus statutory value-added tax and shipping costs = Included in the basic price = Position selectedSpeedy F4 Rev. 02

6" Caster wheel "Flexel System"9000501070 € 39.70puncture-proof3" Skate wheel (80 mm)9000501110 € 50.10puncture-proof4" Skate wheel (100mm)9000501120 € 50.10puncture-proof5" Aluminium rim 3-spoke design"easy running"with replaceable rubber race 3 mm, hard,puncture-proofsilver, anodised9000501200 € 97.30 black9000501201 € 97.305" Aluminium rim 3-spoke design"good shock absorption"with replaceable rubber race 6 mm, mediumhard, puncture-proofsilver, anodised9000501210 € 97.30 black9000501211 € 97.30Safety light-up wheel4" (100 mm)9000501220 € 85.205" (125mm)9000501221 € 85.20puncture-proofCaster forkCaster fork colours, see "Component colours"Caster fork Standard 9000500100-001with bolt-on axle9000500100-002 € 120.90with quick-release axleCaster fork "Heavy duty"for high loadsExtra weight approx. 100 - 150 g9000510111-001 € 40.10with bolt-on axle9000510111-002 € 161.00with quick-release axleSuspension fork9000500160-001 € 292.70with bolt-on axle and5" Aluminium rim "easy running"9000500160-002 € 413.60with quick-release axle and5" Aluminium rim " easy running"Caster fork spare wheel9000500300 € 209.20with quick-release axleArticle is without caster wheel. In case acaster wheel is requested, please put across on a second selection in the categoryCaster wheelsTrack distanceCaster wheel track extension10mm per side900050040015mm per side900050040120mm per side9000500410€ 41.80€ 41.80€ 41.80Drive wheelsInformation on further rim types, versions and availabilities under:www.proactiv-gmbh.deDrive wheel, 18 spoke aluminium rim24“ (ETRTO 540)9000203122with aluminium front hub, spoked radiallyOnly up to a body weight of 70 kg,not with puncture-proof tyres,not suitable for bike mode.Drive wheel, 36 spoke aluminium rimWeightCamberup to 50 kg24“ (ETRTO 540)9000203000with aluminium front hub, spoked radiallyDrive wheel double rim36 spokes24“ (ETRTO 540)9000203100 € 117.1025“ (ETRTO 559)9000203200 € 117.1026“ (ETRTO 590)9000203300with aluminium front hub,spoked radiallyUse with higher loads and body weight> 120 kg!€ 117.10- 7 - 16/05/2014 / The prices are plus statutory value-added tax and shipping costs = Included in the basic price = Position selectedSpeedy F4 Rev. 02

Spinergy running wheel "SpoxSport"with 24 PBO spokes; rim,hub and spokes in black24“ (ETRTO 540)9000203550 € 539.8025“ (ETRTO 559)9000201559 € 539.8026“ (ETRTO 590)9000203555€ 539.80Spinergy "Everyday Light Extreme"with 12 PBO spokes; rim and hub inblack, spokes white24“ (ETRTO 540)9000203554€ 627.20Spinergy "Everyday Light Extreme"with 12 PBO spokes; rim,hub and spokes in black24“ (ETRTO 540)9000203552 € 627.20Decon "Spiderwheel"24“ (ETRTO 540)in black900020371024“ (ETRTO 540)in frame colour9000203711€ 352.00€ 398.00Stainless steel rim handles, aluminiumanodised,Aluminium powder coated, titanium, Ultra-Grip or Dual-Grip possible!Handrimsx = dimension handrim attachment!Handrim attachment: x = 11 mm x = 19mmØ 19 mm stainless steel handrimsfor 24" wheel9000205010-004for 26" wheel9000205010-006Ø 19 mm aluminium handrimssilver anodisedfor 24" wheel9000205019-004Ø 19 mm aluminium handrimspowder coated in the framecolour(Basic colour in two-colour design)for 24" wheel9000205020-004 € 48.00for 26" wheel9000205020-006€ 48.00Ø 19 mm aluminium handrimspolished and hard-anodisedfor 24" wheel9000205030-004 € 115.40for 26" wheel9000205030-006Ø 19 mm titanium handrims€ 115.40for 24" wheel9000205040-004 € 202.50for 26" wheel9000205040-006Ultra-Grip handrims"very good grip"for 24" wheel9000205070-004€ 202.50€ 292.20for 26" wheel9000205070-006 € 292.20Ergo-Grip handrimsfor 24" wheel9000205080-004 € 292.20for 26" wheel9000205080-006 € 292.20Resting attachment to the rim!Dual-Grip handrimsfor 24" wheel9000205110-004for 26" wheel9000205110-006Silicone handrim coverfor 24" hand rim9000205100-004for 26" hand rim9000205100-006Surface without structureEquipment without handrims 9000205990Spoke guardFinger- and spoke guard"transparent"for 24" wheel9000206300-004€ 161.60€ 161.60€ 173.00€ 173.00€ 146.40for 26" wheel € 146.409000206300-006Design and spoke protection film"basket"9000206310-001 € 102.40Only in combination with finger andspoke protection!Design and spoke protection film"silly-bubble"9000206310-002 € 102.40Only in combination with finger andspoke protection!- 8 - 16/05/2014 / The prices are plus statutory value-added tax and shipping costs = Included in the basic price = Position selectedSpeedy F4 Rev. 02

Design and spoke protection film"blue-sky"9000206310-003 € 102.40Only in combination with finger andspoke protection!Design and spoke protection film"colour-stones"9000206310-004 € 102.40Only in combination with finger andspoke protection!TyresSchwalbe "RightRun"High-pressure tyre7.5 bar24x1“ (540-25)9000204000-00425x1“ (559-25)9000204000-00526x1“ (590-25)9000204000-006Schwalbe "DownTown"Tread tyre 7.5 bar24x1“ (540-25)9000204010-004Schwalbe tread tyre 4 bar24x1.3/8“ (540-37)9000204020-00426x1.3/8“ (590-37)9000204020-006Schwalbe "MarathonPlus"with "smart guard" punctureprotection24x1“ (540-25)9000204030-004€ 30.3025x1“ (559-25)9000204030-005€ 30.3026x1“ (590-25)9000204030-006€ 30.30Colour: grey, black wall,10 barSchwalbe "MarathonPlus Evolution"with "smart guard" punctureprotection24x1“ (540-25)9000204030-014 € 30.3025x1“ (559-25)9000204030-015 € 30.3026x1“ (590-25)9000204030-016Colour: black10 bar€ 30.30Schwalbe "SpeedAir"Indoor sports tyre 10 bar24x3/4“ (540-20)9000204121-004 € 30.3025x3/4“ (559-20)9000204121-005 € 30.3026x3/4“ (590-20)9000204121-006Colour: white, black wall€ 30.30Puncture-proof tyre "solid-rubbertyres"24x1“ (540-25)9000204200-004€ 117.10Not in combination with the 18 spoke drivewheel!Puncture protection belt forpneumatic tyres9000206100 € 39.40Accessories24“ MTB spare wheel setwith double rim (ETRTO 540), aluminiumfront hub, quick-release axle and stainlesssteel hand rimMountain bike tyres, selectively:9000203410 € 498.0024x1.75" Continental"TourRIDE Trekking"Brake setting compatible with 24x1" wheel9000203411 € 498.0024x1.75" Continental "Explorer"Brake setting not compatible with 24x1"wheel9000203413 € 498.0024x2.1" Schwalbe"SMART SAM Sport"Brake setting not compatible with 24x1"wheelATTENTION: we charge a surcharge of150.00 € for the use of drum brakesLockable drive wheel axle clip "TetraClip"9000206400 € 117.90Not for Spinergy or Golz drive wheels!Lockable drive wheel axle clip "TetraClip" for Decon Spiderwheel9000206403 € 182.50Hand air compressor with pressuregauge up to 14 bar9000901100 € 79.00- 9 - 16/05/2014 / The prices are plus statutory value-added tax and shipping costs = Included in the basic price = Position selectedSpeedy F4 Rev. 02

Adjustable safety belt with beltbuckle9000902100 € 57.00Adjustable safety belt with hookand loop fastener9000902110 € 45.40Crutch holder with nylon cup9000902310 € 101.10flexibleLight set9000903270 € 76.50with battery and chargerTransport bag for drive wheelsfor 24" wheel9000903530-004Ø76 cm x 2 cmfor 26" wheel9000903530-006Ø83 cm x 2 cmAccessory bag€ 54.60€ 54.609000903600 € 53.8017 cm x 13cm x 5 cmFurther accessories e.g. adaptivebikes, steering attachments, etc. seeseparate dimension sheet orwww.proactiv-gmbh.deI herewith confirm the details listed above____________________________________________________Location, DateSignature (End customer)____________________________________________________Location, DateSignature (Dealer)- 10 - 16/05/2014 / The prices are plus statutory value-added tax and shipping costs = Included in the basic price = Position selectedSpeedy F4 Rev. 02