Living Well Stores — Servicer Information Update

Do you wish to continue to be included in our service network and receive opportunities to perform services for Living Well Stores?

Yes No

Thank you for letting us know.

We're sorry to hear you'd like to be removed from our servicer network. We'll update our records accordingly. If you change your mind in the future, please reach out to us at servicenetwork@livingwellstores.com or call 800-704-8432.

Would you mind sharing your reasons? (optional)

1 Company Information

Servicer ID

Your unique servicer ID — pre-filled automatically.

Company name

Address line 1

Address line 2

City

State

ZIP

Main phone number

Secondary phone number

What email address should we send work orders to

Secondary or additional email address we should copy work orders to

Owner / Manager / Main contact 1

Owner / Manager / Main contact 2

2 Service Network Participation

If you have additional locations where service is provided or dispatched from, how many do you have?

Enter 0 if you operate from a single location.

If your business has multiple locations, provide the addresses here.

Additional Location #1

Address line 1

Address line 2

City

State

ZIP

Email address for this location

Additional Location #2

Address line 1

Address line 2

City

State

ZIP

Email address for this location

Describe the geographical area(s) you serve

Feel free to use local landmarks, highway names, county names, or mile radiuses.

3 Products You Sell / Service / Deliver / Install

Check all that apply for each product category.

Product Category	Sell	Service	Deliver / Install
Power mobility scooters
Electric wheelchairs
Lift recliners
Vehicle lifts (Harmar, Bruno, etc.)
Residential ramp systems
Residential stair lifts
Installation of shower grab bars and other items required to age-in-place
Other (list with commas separating):

Are you able to receive, assemble, and deliver oversized products such as Pride Mobility Wrangler, Golden Eagle, etc.?

Yes No

4 Brands You Sell, Service, and/or Install

Manufacturer	Sell	Service	Deliver / Install
Amramp
Bruno
Drive Medical
Feather
Golden Technology
Harmar
Invacare
Merits
Permobile
Pride Mobility
Other (list with commas separating):

5 Operations

Number of years in business

Do you provide service (choose in-shop or in-home or both):

In shop In home

Facility hours

Enter open/close times or leave blank for closed. Example: 8am–5pm

Mon

Tue

Wed

Thu

Fri

Sat

Sun

6 Rates

In-shop service rate

$ per hour

$ / hr

Billed in increments of

In-home service rate

Trip charge

$ per hour

$ / hr

Billed in increments of

Do you have any additional fees such as for mileage, pickup/drop-off?

7 Certifications & Insurance

What industry certifications do you hold?

How many technicians do you have?

Do your technicians hold any particular certifications?

Do you have liability and/or workers' comp insurance coverage?

Liability insurance Workers' comp

8 Referral Opportunities

Living Well Stores has access to best-in-class products. In addition to power mobility and lift recliners, we also offer consumer/professional bracing, wheelchairs and general DME and with top-tier pricing. If you would like to learn more about our programs where you could earn incentives in exchange for bringing a customer to us and/or getting access to product that you could sell and deliver, would you like to participate?

Yes No

Who should we contact — Name / phone number

Is there additional information you would like us to know?

Your response is saved securely to our records.

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Thank you for being a valuable partner in Living Well Stores' servicer network.

1 Company Information

2 Service Network Participation

3 Products You Sell / Service / Deliver / Install

4 Brands You Sell, Service, and/or Install

5 Operations

6 Rates

7 Certifications & Insurance

8 Referral Opportunities