BIG BOUNDER H-FRAME POWER WHEELCHAIR

1 FAX, PHONE IN OR MAIL COMPLETED FORM TO 21st Century SCIENTIFIC Inc. This is an order ! Our PO No:_____ This is a Quotation Request Only Ship To: Bill To: Company: _____ Company: _____. Address: _____ Address: _____. City:_____ State:____ Zip: _____ City:_____ State:____ Zip: _____. Attention: _____ Attention: _____. Phone:_____ FAX: _____ Phone:_____ FAX: _____. BIG BOUNDER H-FRAME . POWER WHEELCHAIR . User Data: Name:_____ Ht:___'____" Wt:_____ lb. :_____ Disability: _____. Driving Skills: good fair poor Eye-To-Hand Coordination: good fair poor Judgment: good fair poor Equipment Usage: light typical heavy abusive Aggressiveness: timid typical hot rodder Must Operate: on thick carpets in rain and/or snow on steep hills Previous Chair Make & Model: _____.

2 Other Information: _____. _____. New Chair Data: Seat :_____" Seat :_____" Seat :_____". Back Height:_____" Max Overall Width:_____" Max Overall Length:_____". Desired Top Speed Of New Chair ( MPH)_____ POWER Seating Needed: Recline Tilt Elevate Other Other Notes: _____. _____. INSTRUCTIONS FOR FILLING OUT THIS FORM: Thank you for choosing 21st Century SCIENTIFIC, Inc. Since our products tend to be custom, this order /quote form is very detailed. As you complete this form, you will be specifying each parameter of the equipment to be ordered. Accordingly, be patient and review each section carefully.

3 No charge and standard items are usually located near the top of each section, but not always. Check the standard items as well as the custom options in each section to make sure you have not missed anything. You may FAX this form to 21st at (208) 667-6600 for review. A detailed written quote will be faxed back to you. If you need assistance filling out this form (or simply prefer us to do it for you), contact our sales department at (800) 448-3680. There is no charge for our assistance and written quotations. HCPCS codes are not intended to be, nor should they be considered, legal or billing advice.

4 Use of the codes does not ensure coverage or payment for the item. Always verify coverage information with the pay source, attorney or other consultant as needed. This Form Was Completed By:_____ Date:_____ Phone:_____ FAX:_____.. 17th Edition RETAIL order /QUOTE FORM & PRICE LIST - Page 1 - EFFECTIVE: FEBRUARY 15, 2017. BIG BOUNDER H-FRAME POWER WHEELCHAIR . STANDARD FEATURES POPULAR OPTIONS. yFor users up to 500 lbs (700 and 1000 lb options available at extra cost) y Independent drive wheel suspension (500 lb max user weight). ySeat widths from 21 to 48 (by 1 increments) yFront Rigging (footrests or legrests, each with many options).

5 YSeat depths from 16 to 18 (by 1 increments) at no additional cost; deeper at extra cost yQuiet non-slip Panther synchronous gearbelt drive yDurable H-style TIG welded frame using wall steel yArm options yHeadrests yCaptains Seating yFast! Top speeds up to MPH ( kph) yPower 700 / POWER 1000 options to increase max user weight to 700 / 1000 lbs, respectively. ySuper Torque 3 Motors & Brakes (ST3M&B) yPowerful ST4M motors y8 x2 front caster wheels yNon-slip #35 chain drive yPower seating systems: recline, tilt, reverse tilt & seat elevator ySliding dual group 27 battery box y2 or more POWER seating systems combined on same chair yUE1 series premium electronics (6 programs) yDual independent POWER elevating legrests (DIPLR).

6 YBuilt in taillights yBattery condition meter yPSM (through-the-joystick proportional control of POWER seating). ySmart brake release switch (for easy attendant pushing) yProgrammer for electronics yColored (non-black) frame yHeavy duty 12 position adjustable suspension forks ySpecialty controls (sip & puff, switch controls, head arrays, etc.; DX or ASL). yXtra Duty caster barrels and suspension forks (1 fork stems & bearings ID's) yFrame reinforcements yCustom seat depth(>18 ), seat height, back height, etc. y9 metal caster wheels x steel drive wheels yUpholstery and solid seating options wall seat rails and back posts yHand / chin control customizations & mounting options (many to choose from).

7 YBlack powder coated frame yExtended range LFP battery (contact factory). ySheet Metal Seat Pan yLighting package (it's 24V and bright!) yElectric horn (it's LOUD). ySling back upholstery attached with machine screws yElectric leg bag emptier (for unattended leg bag draining) yPositioning straps yQuick adjust clutches (combination belt tensioner and belt release mechanism) yWheel locks (with or without wheel lock extensions). yDetachable desk length arms yReinforced arm mounts yExtended 2 or 3 year warranty yAnti-tipping wheelie wheels yFully automatic 8A charger WARRANTY*. yDetailed Owner's Manual yEasy to service and maintain yONE year warranty on entire chair y5 year warranty on Super Torque 3 & 4 Motor & Brake drive trains**.

8 Y5 year H-FRAME base warranty y2 year H-FRAME seat warranty * Limited warranties some restrictions apply. See complete warranty for more information ** Includes motors, brakes, drive wheels, drive wheel sprockets (drive belts, tires, inner tubes, flat-free inserts, motor sprockets and bearings not included). TOP SPEED CHART. SPEEDS ARE APPROXIMATE. ACTUAL SPEEDS CAN VARY BY AS MUCH AS 10%. CODES NOT LISTED ARE EITHER CUSTOM, NOT AVAILABLE OR NOT POSSIBLE. SUPER TORQUE 3 MOTORS. " " " ". DRIVE WHEELS DRIVE WHEELS. CODE TOP CODE TOP. SPEED SPEED. PANTHER DRIVE CHAIN DRIVE. 313 P080 P24 313 C070 C23 313 P080 P22 313 C070 C21 SUPER TORQUE 4M MOTORS.

9 " " 14" " " " 14" ". DRIVE WHEELS DRIVE WHEELS DRIVE WHEELS DRIVE WHEELS. CODE TOP CODE TOP CODE TOP CODE TOP. SPEED SPEED SPEED SPEED. ============= PANTHER DRIVES ============= ============= CHAIN DRIVES ============= . 4M13 P080 P28 4M14 P080 P28 4M13 C060 C25 4M14 C060 C25 4M13 P080 P26 4M14 P080 P26 4M13 C060 C23 4M14 C060 C23 4M13 P080 P24 4M14 P080 P24 4M13 C060 C21 4M14 C060 C21 4M13 P080 P22 4M14 P080 P22 4M13 C070 C23 4M14 C070 C23 4M13 C070 C21 4M14 C070 C21 DRIVE TRAIN CONFIGURATION NOTES: 1) Generally, configurations with higher top speeds tend to have reduced hill-climbing capability (less torque) and reduced range.

10 2) Do not order drive train configurations with top speeds that exceed the physical or mental capabilities of the driver. Fast chairs are usually not appropriate for children. 3) If the motor sprocket size is increased, speed increases, and hill climbing capability decreases. If the drive wheel sprocket size is decreased, speed increases, and hill climbing capability decreases. 4) The Panther and chain drive systems supplied with BIG BOUNDER H-FRAME chairs do not slip in the rain or snow. 5) The Panther and chain drive systems supplied with BIG BOUNDER H-FRAME chairs are quiet but can be heard over the motors, and a slight vibration can be felt.