Title {!! Form::text('title', \request("country_id"), ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!} @lang("content.first_name") {!! Form::text('first_name', \request("country_id"), ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!} @lang("content.last_name") {!! Form::text('last_name', \request("country_id"), ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!} Middle Name {!! Form::text('middle_name', \request("country_id"), ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!}
Home Address {!! Form::text('middle_name', \request("country_id"), ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!} @lang("content.country") {!! Form::select('country_id', $countries, \request("country_id"), ['class' => 'input-sm form-control', 'id' => 'location']) !!} @lang("content.city") {!! Form::select('city_id', [], \request("city_id"), ['class' => 'input-sm form-control', 'id' => 'location']) !!} @lang("content.other") {!! Form::text('middle_name', \request("country_id"), ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!}
@lang("content.phone") {!! Form::text('phone', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!} #2 {!! Form::text('phone', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!} @lang("content.mobile") {!! Form::text('mobile', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!} #2 {!! Form::text('phone', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!}
Fax {!! Form::text('fax', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!} E-mail {!! Form::text('email', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!}
Passport/NRIC No. {!! Form::text('passport_number', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!} Occupation {!! Form::select('city_id', [], \request("city_id"), ['class' => 'input-sm form-control', 'id' => 'location']) !!} @lang("content.other") {!! Form::text('email', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!}
Business Address {!! Form::text('middle_name', \request("country_id"), ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!} @lang("content.country") {!! Form::select('country_id', $countries, \request("country_id"), ['class' => 'input-sm form-control', 'id' => 'location']) !!} @lang("content.city") {!! Form::select('city_id', [], \request("city_id"), ['class' => 'input-sm form-control', 'id' => 'location']) !!} @lang("content.other") {!! Form::text('middle_name', \request("country_id"), ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!}
Business Phone {!! Form::text('phone', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!} #2 {!! Form::text('phone', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!} Frequent Flyer No. {!! Form::text('mobile', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!}

Flight Itinerary

Qty @lang("content.flight_number") Date & Time From Date & Time To
{!! Form::text('title', \request("country_id"), ['class'=>'form-control input-sm', 'placeholder'=>'Qty', 'id'=>'title']) !!} {!! Form::text('first_name', \request("country_id"), ['class'=>'form-control input-sm', 'placeholder'=>'Flight Number', 'id'=>'title']) !!} {!! Form::text('dateFrom', \request("dateFrom"), ['class'=>'form-control dateTimeFrom input-sm', 'placeholder'=>'Date & Time From', 'id'=>'dateFrom']) !!} {!! Form::text('dateTo', \request("dateTo"), ['class'=>'form-control dateTimeTo input-sm', 'placeholder'=>'Date & Time To', 'id'=>'dateTo']) !!}
{!! Form::text('title', \request("country_id"), ['class'=>'form-control input-sm', 'placeholder'=>'Qty', 'id'=>'title']) !!} {!! Form::text('first_name', \request("country_id"), ['class'=>'form-control input-sm', 'placeholder'=>'Flight Number', 'id'=>'title']) !!} {!! Form::text('dateFrom', \request("dateFrom"), ['class'=>'form-control dateTimeFrom input-sm', 'placeholder'=>'Date & Time From', 'id'=>'dateFrom']) !!} {!! Form::text('dateTo', \request("dateTo"), ['class'=>'form-control dateTimeTo input-sm', 'placeholder'=>'Date & Time To', 'id'=>'dateTo']) !!}
{!! Form::text('title', \request("country_id"), ['class'=>'form-control input-sm', 'placeholder'=>'Qty', 'id'=>'title']) !!} {!! Form::text('first_name', \request("country_id"), ['class'=>'form-control input-sm', 'placeholder'=>'Flight Number', 'id'=>'title']) !!} {!! Form::text('dateFrom', \request("dateFrom"), ['class'=>'form-control dateTimeFrom input-sm', 'placeholder'=>'Date & Time From', 'id'=>'dateFrom']) !!} {!! Form::text('dateTo', \request("dateTo"), ['class'=>'form-control dateTimeTo input-sm', 'placeholder'=>'Date & Time To', 'id'=>'dateTo']) !!}
No. of bag checked {!! Form::text('phone', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!} No. of bag received {!! Form::text('phone', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!} No. of bag missing {!! Form::text('mobile', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!}
Weight of each bag missing {!! Form::text('phone', null, ['class'=>'form-control input-sm input-80 float-left', 'placeholder'=>'Title', 'id'=>'title']) !!}
Passenger Ticket No.(attach copy) {!! Form::text('fax', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!} Excess Baggage Ticket No. (attach copy) {!! Form::text('email', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!}
Baggage checked at: Baggage was last seen at: {!! Form::text('mobile', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!}
Baggage was checked to (city shown on tag) {!! Form::text('fax', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!} on (Airline/Flight Number) {!! Form::text('email', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!}
Final Destination {!! Form::text('fax', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!} Was baggage rechecked and new tags issued? If yes, what airport {!! Form::text('mobile', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!}
Was baggage seen there? Was baggage available at customs?
If original routing was changed after starting trip If yes, please specify: {!! Form::text('mobile', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!}
Was airline notified of loss immediately? If yes, at what office: {!! Form::text('mobile', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!}
Date & Time {!! Form::text('fax', null, ['class'=>'form-control dateTimeFrom input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!} By telephone or in person {!! Form::text('email', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!}
If airline was not notified, state reason: {!! Form::textarea('fax', null, ['class'=>'form-control input-sm', 'rows' => 2, 'placeholder'=>'Title', 'id'=>'title']) !!}
Was the loss been reported to any other airline? If yes, to whom? {!! Form::text('mobile', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!}
Any other relevant details {!! Form::textarea('fax', null, ['class'=>'form-control input-sm', 'rows' => 2, 'placeholder'=>'Title', 'id'=>'title']) !!}
Traveling with: If Group, please specify name of group if have: {!! Form::text('mobile', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!}
Contents of the missing baggage are:
Description of missing baggage (chart attached): {!! Form::text('fax', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!} @lang("content.type") {!! Form::text('email', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!} Color {!! Form::text('email', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!}
Material {!! Form::text('fax', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!} Brand {!! Form::text('email', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!} Cost New {!! Form::text('email', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!} Purchase Date {!! Form::text('email', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!}
Descriptive elements (check if applicable):
Description of missing contents � List separately if more than one passenger or bag involved
Qty Item Description (Color/Material/Brand Label/Store Name Purchase Date Cost New
{!! Form::text('mis_qty[]', \request("country_id"), ['class'=>'form-control input-sm', 'placeholder'=>'Qty', 'id'=>'title']) !!} {!! Form::text('mis_item[]', \request("country_id"), ['class'=>'form-control input-sm', 'placeholder'=>'Item', 'id'=>'title']) !!} {!! Form::text('mis_desc[]', \request("country_id"), ['class'=>'form-control input-sm', 'placeholder'=>'Description (Color/Material/Brand Label/Store Name', 'id'=>'title']) !!} {!! Form::text('mis_date[]', \request("country_id"), ['class'=>'form-control input-sm', 'placeholder'=>'Purchase Date', 'id'=>'title']) !!} {!! Form::text('mis_cost[]', \request("country_id"), ['class'=>'form-control input-sm', 'placeholder'=>'Cost New', 'id'=>'title']) !!}
{!! Form::text('mis_qty[]', \request("country_id"), ['class'=>'form-control input-sm', 'placeholder'=>'Qty', 'id'=>'title']) !!} {!! Form::text('mis_item[]', \request("country_id"), ['class'=>'form-control input-sm', 'placeholder'=>'Item', 'id'=>'title']) !!} {!! Form::text('mis_desc[]', \request("country_id"), ['class'=>'form-control input-sm', 'placeholder'=>'Description (Color/Material/Brand Label/Store Name', 'id'=>'title']) !!} {!! Form::text('mis_date[]', \request("country_id"), ['class'=>'form-control input-sm', 'placeholder'=>'Purchase Date', 'id'=>'title']) !!} {!! Form::text('mis_cost[]', \request("country_id"), ['class'=>'form-control input-sm', 'placeholder'=>'Cost New', 'id'=>'title']) !!}
{!! Form::text('mis_qty[]', \request("country_id"), ['class'=>'form-control input-sm', 'placeholder'=>'Qty', 'id'=>'title']) !!} {!! Form::text('mis_item[]', \request("country_id"), ['class'=>'form-control input-sm', 'placeholder'=>'Item', 'id'=>'title']) !!} {!! Form::text('mis_desc[]', \request("country_id"), ['class'=>'form-control input-sm', 'placeholder'=>'Description (Color/Material/Brand Label/Store Name', 'id'=>'title']) !!} {!! Form::text('mis_date[]', \request("country_id"), ['class'=>'form-control input-sm', 'placeholder'=>'Purchase Date', 'id'=>'title']) !!} {!! Form::text('mis_cost[]', \request("country_id"), ['class'=>'form-control input-sm', 'placeholder'=>'Cost New', 'id'=>'title']) !!}
@lang("content.total") {!! Form::text('total_cost', \request("country_id"), ['class'=>'form-control input-sm', 'placeholder'=>'Total Cost', 'id'=>'title']) !!}
Do you have private insurance covering this loss?
If so, state company and address::
{!! Form::text('mobile', null, ['class'=>'form-control input-sm', 'placeholder'=>'Title', 'id'=>'title']) !!}
It is expressly understood and agreed by me that the furnishing of this form and any assistance furnished me by employees of AVBIS, are acts of courtesy and shall not constitute a wavier of any rights or an admission of liability by or on the part of AVBIS its employees or agents. Any other information and/or documents relating to this statement which are required by AVBIS, will be furnished by me upon request and shall be considered part of this statement.
To serve you better, please: 1. Sign your claim form. 2. Attach a copy of your ticket receipt. 3. Attach your Baggage claim checks
I do hereby warrant the foregoing statement and those on the accompanying forms to be accurate, complete, true and I hereby make a claim against AVBIS, in the amount of $ _______________________ for a loss occurring on __________________________.
Signature_______________________ Date__________________________