{"id":1851,"date":"2021-11-24T08:14:35","date_gmt":"2021-11-24T08:14:35","guid":{"rendered":"http:\/\/localhost\/aga24h_2023\/?page_id=1851"},"modified":"2025-11-07T13:37:04","modified_gmt":"2025-11-07T06:37:04","slug":"online-claim","status":"publish","type":"page","link":"https:\/\/allianz-assistance.co.th\/travel\/online-claim\/","title":{"rendered":"E-Document Submission"},"content":{"rendered":"<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_1' style='display:none'><div id='gf_1' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">E-Document Submission<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/travel\/wp-json\/wp\/v2\/pages\/1851#gf_1' data-formid='1' >\n        <div id='gf_progressbar_wrapper_1' class='gf_progressbar_wrapper'>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>4<\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_25' style='width:25%;'><span>25%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_1_1' class='gform_page ' >\n                                    <div class='gform_page_fields'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_1_8\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_8\"><h3> \u0e02\u0e49\u0e2d\u0e15\u0e01\u0e25\u0e07\u0e43\u0e19\u0e01\u0e32\u0e23\u0e43\u0e0a\u0e49\u0e1a\u0e23\u0e34\u0e01\u0e32\u0e23 \/ Term and Condition<\/h3>\n<div>\n<ul>\n<li> \u0e01\u0e23\u0e38\u0e13\u0e32\u0e22\u0e37\u0e19\u0e22\u0e31\u0e19\u0e15\u0e31\u0e27\u0e15\u0e19\u0e14\u0e49\u0e27\u0e22 \u0e0a\u0e37\u0e48\u0e2d-\u0e2a\u0e01\u0e38\u0e25 \u0e41\u0e25\u0e30\u0e40\u0e25\u0e02\u0e17\u0e35\u0e48\u0e01\u0e23\u0e21\u0e18\u0e23\u0e23\u0e21\u0e4c\u0e02\u0e2d\u0e07\u0e1c\u0e39\u0e49\u0e40\u0e2d\u0e32\u0e1b\u0e23\u0e30\u0e01\u0e31\u0e19  \/ Please provide the policy and name to verified the insured person<\/li>\n<li>\u0e40\u0e1e\u0e37\u0e48\u0e2d\u0e1c\u0e25\u0e1b\u0e23\u0e30\u0e42\u0e22\u0e0a\u0e19\u0e4c\u0e02\u0e2d\u0e07\u0e17\u0e48\u0e32\u0e19 \u0e01\u0e23\u0e38\u0e13\u0e32\u0e40\u0e15\u0e23\u0e35\u0e22\u0e21\u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e2a\u0e33\u0e04\u0e31\u0e0d\u0e2a\u0e33\u0e2b\u0e23\u0e31\u0e1a\u0e01\u0e32\u0e23\u0e41\u0e08\u0e49\u0e07\u0e40\u0e04\u0e25\u0e21\u0e43\u0e19\u0e2b\u0e31\u0e27\u0e02\u0e49\u0e2d\u0e17\u0e35\u0e48\u0e17\u0e48\u0e32\u0e19\u0e15\u0e49\u0e2d\u0e07\u0e01\u0e32\u0e23\u0e43\u0e2b\u0e49\u0e1e\u0e23\u0e49\u0e2d\u0e21 \/ For your own benefit, please prepare all document required<\/li>\n<li>\u0e1a\u0e23\u0e34\u0e29\u0e31\u0e17\u0e2f \u0e2d\u0e32\u0e08\u0e02\u0e2d\u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e40\u0e1e\u0e34\u0e48\u0e21\u0e40\u0e15\u0e34\u0e21\u0e08\u0e32\u0e01\u0e17\u0e35\u0e48\u0e23\u0e30\u0e1a\u0e38\u0e44\u0e27\u0e49 \u0e43\u0e19\u0e01\u0e23\u0e13\u0e35\u0e17\u0e35\u0e48\u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e19\u0e31\u0e49\u0e19\u0e08\u0e33\u0e40\u0e1b\u0e47\u0e19\u0e15\u0e48\u0e2d\u0e01\u0e32\u0e23\u0e1e\u0e34\u0e08\u0e32\u0e23\u0e13\u0e32\u0e2d\u0e19\u0e38\u0e21\u0e31\u0e15\u0e34 \/ In certain circumstance, more document may be required to substantiate the claim<\/li>\n<li> \u0e1a\u0e23\u0e34\u0e29\u0e31\u0e17\u0e2f \u0e08\u0e30\u0e14\u0e33\u0e40\u0e19\u0e34\u0e19\u0e01\u0e32\u0e23\u0e1e\u0e34\u0e08\u0e32\u0e23\u0e13\u0e32\u0e04\u0e48\u0e32\u0e2a\u0e34\u0e19\u0e44\u0e2b\u0e21\u0e17\u0e14\u0e41\u0e17\u0e19\u0e20\u0e32\u0e22\u0e43\u0e19 15 \u0e27\u0e31\u0e19 \u0e19\u0e31\u0e1a\u0e15\u0e31\u0e49\u0e07\u0e41\u0e15\u0e48\u0e27\u0e31\u0e19\u0e17\u0e35\u0e48\u0e1a\u0e23\u0e34\u0e29\u0e31\u0e17\u0e2f \u0e44\u0e14\u0e49\u0e23\u0e31\u0e1a\u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e2b\u0e25\u0e31\u0e01\u0e10\u0e32\u0e19\u0e17\u0e35\u0e48\u0e16\u0e39\u0e01\u0e15\u0e49\u0e2d\u0e07\u0e41\u0e25\u0e30\u0e04\u0e23\u0e1a\u0e16\u0e49\u0e27\u0e19 \u0e08\u0e32\u0e01\u0e17\u0e48\u0e32\u0e19\u0e40\u0e23\u0e35\u0e22\u0e1a\u0e23\u0e49\u0e2d\u0e22\u0e41\u0e25\u0e49\u0e27 \/ Once all document required have been submit, the claim process would take up to 15 days<\/li>\n<li> \u0e02\u0e2d\u0e2a\u0e07\u0e27\u0e19\u0e2a\u0e34\u0e17\u0e18\u0e34\u0e4c\u0e01\u0e32\u0e23\u0e41\u0e08\u0e49\u0e07\u0e40\u0e04\u0e25\u0e21\u0e1c\u0e48\u0e32\u0e19\u0e23\u0e30\u0e1a\u0e1a\u0e2d\u0e2d\u0e19\u0e44\u0e25\u0e19\u0e4c\u0e40\u0e09\u0e1e\u0e32\u0e30\u0e01\u0e23\u0e21\u0e18\u0e23\u0e23\u0e21\u0e4c\u0e1b\u0e23\u0e30\u0e01\u0e31\u0e19\u0e20\u0e31\u0e22\u0e01\u0e32\u0e23\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07 Allianz Travel \u0e40\u0e17\u0e48\u0e32\u0e19\u0e31\u0e49\u0e19 \/ Online Claim will accept only travel insurance provided by Allianz Travel<\/li>\n<\/ul>\n<\/div><\/div><div id=\"field_1_4\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_4\"><h3 class=\"gsection_title\">1. \u0e23\u0e32\u0e22\u0e25\u0e30\u0e40\u0e2d\u0e35\u0e22\u0e14\u0e01\u0e32\u0e23\u0e40\u0e04\u0e25\u0e21 \/ CLAIM INFORMATION<\/h3><\/div><div id=\"field_1_1\"  class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_1\"><label class='gfield_label gform-field-label' for='input_1_1' >\u0e2b\u0e31\u0e27\u0e02\u0e49\u0e2d\u0e17\u0e35\u0e48\u0e15\u0e49\u0e2d\u0e07\u0e01\u0e32\u0e23\u0e40\u0e23\u0e35\u0e22\u0e01\u0e23\u0e49\u0e2d\u0e07\u0e2a\u0e34\u0e19\u0e44\u0e2b\u0e21 \/ Please indicate which benefits you are claiming<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_1' id='input_1_1' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='\u0e04\u0e48\u0e32\u0e23\u0e31\u0e01\u0e29\u0e32\u0e1e\u0e22\u0e32\u0e1a\u0e32\u0e25 \/ Medical Expense' >\u0e04\u0e48\u0e32\u0e23\u0e31\u0e01\u0e29\u0e32\u0e1e\u0e22\u0e32\u0e1a\u0e32\u0e25 \/ Medical Expense<\/option><option value='\u0e2a\u0e31\u0e21\u0e20\u0e32\u0e23\u0e30\u0e25\u0e48\u0e32\u0e0a\u0e49\u0e32 \/ Baggage Delay' >\u0e2a\u0e31\u0e21\u0e20\u0e32\u0e23\u0e30\u0e25\u0e48\u0e32\u0e0a\u0e49\u0e32 \/ Baggage Delay<\/option><option value='\u0e40\u0e17\u0e35\u0e48\u0e22\u0e27\u0e1a\u0e34\u0e19\u0e25\u0e48\u0e32\u0e0a\u0e49\u0e32 \/ Flight Delay' >\u0e40\u0e17\u0e35\u0e48\u0e22\u0e27\u0e1a\u0e34\u0e19\u0e25\u0e48\u0e32\u0e0a\u0e49\u0e32 \/ Flight Delay<\/option><option value='\u0e01\u0e32\u0e23\u0e1e\u0e25\u0e32\u0e14\u0e01\u0e32\u0e23\u0e15\u0e48\u0e2d\u0e40\u0e17\u0e35\u0e48\u0e22\u0e27\u0e1a\u0e34\u0e19  \/ Missed Connecting Flight' >\u0e01\u0e32\u0e23\u0e1e\u0e25\u0e32\u0e14\u0e01\u0e32\u0e23\u0e15\u0e48\u0e2d\u0e40\u0e17\u0e35\u0e48\u0e22\u0e27\u0e1a\u0e34\u0e19  \/ Missed Connecting Flight<\/option><option value='\u0e01\u0e32\u0e23\u0e1a\u0e2d\u0e01\u0e40\u0e25\u0e34\u0e01\u0e01\u0e32\u0e23\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07 \u0e2b\u0e23\u0e37\u0e2d \u0e25\u0e14\u0e08\u0e33\u0e19\u0e27\u0e19\u0e27\u0e31\u0e19\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07 \/ Trip Cancellation or Trip Curtailment' >\u0e01\u0e32\u0e23\u0e1a\u0e2d\u0e01\u0e40\u0e25\u0e34\u0e01\u0e01\u0e32\u0e23\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07 \u0e2b\u0e23\u0e37\u0e2d \u0e25\u0e14\u0e08\u0e33\u0e19\u0e27\u0e19\u0e27\u0e31\u0e19\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07 \/ Trip Cancellation or Trip Curtailment<\/option><option value='\u0e01\u0e32\u0e23\u0e2a\u0e39\u0e0d\u0e2b\u0e32\u0e22\u0e02\u0e2d\u0e07\u0e2a\u0e31\u0e21\u0e20\u0e32\u0e23\u0e30 \u0e2b\u0e23\u0e37\u0e2d \u0e02\u0e2d\u0e07\u0e2a\u0e48\u0e27\u0e19\u0e15\u0e31\u0e27 \/ Loss of Baggage or Personal Effects' >\u0e01\u0e32\u0e23\u0e2a\u0e39\u0e0d\u0e2b\u0e32\u0e22\u0e02\u0e2d\u0e07\u0e2a\u0e31\u0e21\u0e20\u0e32\u0e23\u0e30 \u0e2b\u0e23\u0e37\u0e2d \u0e02\u0e2d\u0e07\u0e2a\u0e48\u0e27\u0e19\u0e15\u0e31\u0e27 \/ Loss of Baggage or Personal Effects<\/option><option value='\u0e04\u0e48\u0e32\u0e2a\u0e48\u0e27\u0e19\u0e41\u0e23\u0e01\u0e02\u0e2d\u0e07\u0e23\u0e16\u0e40\u0e0a\u0e48\u0e32 \/ Rental Vehicle Excess' >\u0e04\u0e48\u0e32\u0e2a\u0e48\u0e27\u0e19\u0e41\u0e23\u0e01\u0e02\u0e2d\u0e07\u0e23\u0e16\u0e40\u0e0a\u0e48\u0e32 \/ Rental Vehicle Excess<\/option><option value='\u0e04\u0e27\u0e32\u0e21\u0e40\u0e2a\u0e35\u0e22\u0e2b\u0e32\u0e22\u0e02\u0e2d\u0e07\u0e2a\u0e31\u0e21\u0e20\u0e32\u0e23\u0e30 \/ Baggage Damage' >\u0e04\u0e27\u0e32\u0e21\u0e40\u0e2a\u0e35\u0e22\u0e2b\u0e32\u0e22\u0e02\u0e2d\u0e07\u0e2a\u0e31\u0e21\u0e20\u0e32\u0e23\u0e30 \/ Baggage Damage<\/option><option value='\u0e2d\u0e37\u0e48\u0e19\u0e46 \/ Others' >\u0e2d\u0e37\u0e48\u0e19\u0e46 \/ Others<\/option><\/select><\/div><\/div><div id=\"field_1_6\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_6\"><h3> \u0e42\u0e1b\u0e23\u0e14\u0e40\u0e15\u0e23\u0e35\u0e22\u0e21\u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e01\u0e32\u0e23\u0e40\u0e04\u0e25\u0e21\u0e43\u0e2b\u0e49\u0e04\u0e23\u0e1a\u0e16\u0e49\u0e27\u0e19 \/ Please prepare the required document<\/h3>\n<div id=\"medical-expense\">\n<ul>\n<li> \u0e2a\u0e33\u0e40\u0e19\u0e32\u0e2b\u0e19\u0e31\u0e07\u0e2a\u0e37\u0e2d\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07 \/ Certified Copy Of Passport<\/li>\n<li> \u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e01\u0e32\u0e23\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07 \u0e2b\u0e23\u0e37\u0e2d\u0e15\u0e31\u0e4b\u0e27\u0e42\u0e14\u0e22\u0e2a\u0e32\u0e23\u0e40\u0e04\u0e23\u0e37\u0e48\u0e2d\u0e07\u0e1a\u0e34\u0e19 \/ Traveling document or E-ticket or Boarding Pass<\/li>\n<li> \u0e43\u0e1a\u0e23\u0e31\u0e1a\u0e23\u0e2d\u0e07\u0e41\u0e1e\u0e17\u0e22\u0e4c \/ Physician\u2019s report describing significant symptoms<\/li>\n<li> \u0e43\u0e1a\u0e40\u0e2a\u0e23\u0e47\u0e08\u0e04\u0e48\u0e32\u0e23\u0e31\u0e01\u0e29\u0e32\u0e1e\u0e22\u0e32\u0e1a\u0e32\u0e25 \/ Medical Receipt or Invoice<\/li>\n<\/ul>\n<\/div><\/div><div id=\"field_1_7\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_7\"><h3> \u0e42\u0e1b\u0e23\u0e14\u0e40\u0e15\u0e23\u0e35\u0e22\u0e21\u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e01\u0e32\u0e23\u0e40\u0e04\u0e25\u0e21\u0e43\u0e2b\u0e49\u0e04\u0e23\u0e1a\u0e16\u0e49\u0e27\u0e19 \/ Please prepare the required document<\/h3>\n<div id=\"flight-delay\">\n<ul>\n<li> \u0e2a\u0e33\u0e40\u0e19\u0e32\u0e2b\u0e19\u0e31\u0e07\u0e2a\u0e37\u0e2d\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07  \/ Certified Copy Of Passport<\/li>\n<li> \u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e01\u0e32\u0e23\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07 \u0e2b\u0e23\u0e37\u0e2d\u0e15\u0e31\u0e4b\u0e27\u0e42\u0e14\u0e22\u0e2a\u0e32\u0e23\u0e40\u0e04\u0e23\u0e37\u0e48\u0e2d\u0e07\u0e1a\u0e34\u0e19 \/ Traveling document or E-ticket or Boarding Pass<\/li>\n<li> \u0e08\u0e14\u0e2b\u0e21\u0e32\u0e22\u0e08\u0e32\u0e01\u0e02\u0e19\u0e2a\u0e48\u0e07\u0e41\u0e08\u0e49\u0e07\u0e2a\u0e32\u0e40\u0e2b\u0e15\u0e38\u0e01\u0e32\u0e23\u0e25\u0e48\u0e32\u0e0a\u0e49\u0e32 \/ Letter from carrier detailing the reason<\/li>\n<\/ul>\n<\/div><\/div><div id=\"field_1_9\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_9\"><h3> \u0e42\u0e1b\u0e23\u0e14\u0e40\u0e15\u0e23\u0e35\u0e22\u0e21\u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e01\u0e32\u0e23\u0e40\u0e04\u0e25\u0e21\u0e43\u0e2b\u0e49\u0e04\u0e23\u0e1a\u0e16\u0e49\u0e27\u0e19 \/ Please prepare the required document<\/h3>\n<div id=\"missed-connecing-flight\">\n<ul>\n<li> \u0e2a\u0e33\u0e40\u0e19\u0e32\u0e2b\u0e19\u0e31\u0e07\u0e2a\u0e37\u0e2d\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07  \/ Certified Copy Of Passport<\/li>\n<li> \u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e01\u0e32\u0e23\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07 \u0e2b\u0e23\u0e37\u0e2d\u0e15\u0e31\u0e4b\u0e27\u0e42\u0e14\u0e22\u0e2a\u0e32\u0e23\u0e40\u0e04\u0e23\u0e37\u0e48\u0e2d\u0e07\u0e1a\u0e34\u0e19 \/ Traveling document or E-ticket or Boarding Pass<\/li>\n<li> \u0e08\u0e14\u0e2b\u0e21\u0e32\u0e22\u0e08\u0e32\u0e01\u0e02\u0e19\u0e2a\u0e48\u0e07\u0e41\u0e08\u0e49\u0e07\u0e2a\u0e32\u0e40\u0e2b\u0e15\u0e38\u0e01\u0e32\u0e23\u0e25\u0e48\u0e32\u0e0a\u0e49\u0e32 \/ Letter from carrier detailing the reason<\/li>\n<\/ul>\n<\/div><\/div><div id=\"field_1_10\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_10\"><h3> \u0e42\u0e1b\u0e23\u0e14\u0e40\u0e15\u0e23\u0e35\u0e22\u0e21\u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e01\u0e32\u0e23\u0e40\u0e04\u0e25\u0e21\u0e43\u0e2b\u0e49\u0e04\u0e23\u0e1a\u0e16\u0e49\u0e27\u0e19 \/ Please prepare the required document<\/h3>\n<div id=\"rental-vehicle-excess\">\n<ul>\n<li>\u0e2a\u0e33\u0e40\u0e19\u0e32\u0e2b\u0e19\u0e31\u0e07\u0e2a\u0e37\u0e2d\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07  \/ Certified Copy Of Passport<\/li>\n<li>\u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e01\u0e32\u0e23\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07 \u0e2b\u0e23\u0e37\u0e2d\u0e15\u0e31\u0e4b\u0e27\u0e42\u0e14\u0e22\u0e2a\u0e32\u0e23\u0e40\u0e04\u0e23\u0e37\u0e48\u0e2d\u0e07\u0e1a\u0e34\u0e19 \/ Traveling document or E-ticket or Boarding Pass<\/li>\n<li>\u0e2a\u0e31\u0e0d\u0e0d\u0e32\u0e01\u0e32\u0e23\u0e40\u0e0a\u0e48\u0e32 \/ Rental Agreement<\/li>\n<li>\u0e08\u0e14\u0e2b\u0e21\u0e32\u0e22\u0e41\u0e08\u0e49\u0e07\u0e01\u0e32\u0e23\u0e40\u0e2a\u0e35\u0e22\u0e2b\u0e32\u0e22 \/ Damage report<\/li>\n<li>\u0e43\u0e1a\u0e40\u0e2a\u0e23\u0e47\u0e08\u0e04\u0e48\u0e32\u0e40\u0e2a\u0e35\u0e22\u0e2b\u0e32\u0e22\u0e2a\u0e48\u0e27\u0e19\u0e41\u0e23\u0e01 \/ Invoicing or Receipts of excess amount<\/li>\n<\/ul>\n<\/div><\/div><div id=\"field_1_11\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_11\"><h3> \u0e42\u0e1b\u0e23\u0e14\u0e40\u0e15\u0e23\u0e35\u0e22\u0e21\u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e01\u0e32\u0e23\u0e40\u0e04\u0e25\u0e21\u0e43\u0e2b\u0e49\u0e04\u0e23\u0e1a\u0e16\u0e49\u0e27\u0e19 \/ Please prepare the required document<\/h3>\n<div id=\"trip-cancellation\">\n<ul>\n<li>\u0e2a\u0e33\u0e40\u0e19\u0e32\u0e2b\u0e19\u0e31\u0e07\u0e2a\u0e37\u0e2d\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07  \/ Certified Copy Of Passport<\/li>\n<li>\u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e01\u0e32\u0e23\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07 \u0e2b\u0e23\u0e37\u0e2d\u0e15\u0e31\u0e4b\u0e27\u0e42\u0e14\u0e22\u0e2a\u0e32\u0e23\u0e40\u0e04\u0e23\u0e37\u0e48\u0e2d\u0e07\u0e1a\u0e34\u0e19 \/ Traveling document or E-ticket or Boarding Pass<\/li>\n<li> \u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e22\u0e37\u0e19\u0e22\u0e31\u0e19\u0e01\u0e32\u0e23\u0e08\u0e48\u0e32\u0e22\u0e40\u0e07\u0e34\u0e19 \u0e41\u0e25\u0e30\u0e01\u0e32\u0e23\u0e02\u0e2d\u0e04\u0e37\u0e19\u0e40\u0e07\u0e34\u0e19 \/ Confirmation of payment &#038; Confirmation of refund<\/li>\n<li>\u0e08\u0e14\u0e2b\u0e21\u0e32\u0e22\u0e08\u0e32\u0e01\u0e02\u0e19\u0e2a\u0e48\u0e07\u0e41\u0e08\u0e49\u0e07\u0e2a\u0e32\u0e40\u0e2b\u0e15\u0e38 \u0e2b\u0e23\u0e37\u0e2d \/ Letter from carrier detailing the reason<\/li>\n<li>\u0e43\u0e1a\u0e23\u0e31\u0e1a\u0e23\u0e2d\u0e07\u0e41\u0e1e\u0e17\u0e22\u0e4c \/ Physician\u2019s report describing significant symptoms<\/li>\n<\/ul>\n<\/div><\/div><div id=\"field_1_12\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_12\"><h3> \u0e42\u0e1b\u0e23\u0e14\u0e40\u0e15\u0e23\u0e35\u0e22\u0e21\u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e01\u0e32\u0e23\u0e40\u0e04\u0e25\u0e21\u0e43\u0e2b\u0e49\u0e04\u0e23\u0e1a\u0e16\u0e49\u0e27\u0e19 \/ Please prepare the required document<\/h3>\n<div id=\"baggage-delay\">\n<ul>\n<li>\u0e2a\u0e33\u0e40\u0e19\u0e32\u0e2b\u0e19\u0e31\u0e07\u0e2a\u0e37\u0e2d\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07  \/ Certified Copy Of Passport<\/li>\n<li>\u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e01\u0e32\u0e23\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07 \u0e2b\u0e23\u0e37\u0e2d\u0e15\u0e31\u0e4b\u0e27\u0e42\u0e14\u0e22\u0e2a\u0e32\u0e23\u0e40\u0e04\u0e23\u0e37\u0e48\u0e2d\u0e07\u0e1a\u0e34\u0e19 \/ Traveling document or E-ticket or Boarding Pass<\/li>\n<li>\u0e08\u0e14\u0e2b\u0e21\u0e32\u0e22\u0e23\u0e30\u0e1a\u0e38\u0e27\u0e31\u0e19\u0e41\u0e25\u0e30\u0e40\u0e27\u0e25\u0e32\u0e17\u0e35\u0e48\u0e23\u0e31\u0e1a\u0e2a\u0e31\u0e21\u0e20\u0e32\u0e23\u0e30\u0e08\u0e32\u0e01\u0e02\u0e19\u0e2a\u0e48\u0e07 \/ Report issued by Delivery Service stating date and time<\/li>\n<\/ul>\n<\/div><\/div><div id=\"field_1_13\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_13\"><h3> \u0e42\u0e1b\u0e23\u0e14\u0e40\u0e15\u0e23\u0e35\u0e22\u0e21\u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e01\u0e32\u0e23\u0e40\u0e04\u0e25\u0e21\u0e43\u0e2b\u0e49\u0e04\u0e23\u0e1a\u0e16\u0e49\u0e27\u0e19 \/ Please prepare the required document<\/h3>\n<div id=\"lost-baggage\">\n<ul>\n<li>\u0e2a\u0e33\u0e40\u0e19\u0e32\u0e2b\u0e19\u0e31\u0e07\u0e2a\u0e37\u0e2d\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07  \/ Certified Copy Of Passport<\/li>\n<li>\u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e01\u0e32\u0e23\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07 \u0e2b\u0e23\u0e37\u0e2d\u0e15\u0e31\u0e4b\u0e27\u0e42\u0e14\u0e22\u0e2a\u0e32\u0e23\u0e40\u0e04\u0e23\u0e37\u0e48\u0e2d\u0e07\u0e1a\u0e34\u0e19 \/ Traveling document or E-ticket or Boarding Pass<\/li>\n<li>\u0e2b\u0e25\u0e31\u0e01\u0e10\u0e32\u0e19\u0e41\u0e2a\u0e14\u0e07\u0e04\u0e27\u0e32\u0e21\u0e40\u0e1b\u0e47\u0e19\u0e40\u0e08\u0e49\u0e32\u0e02\u0e2d\u0e07 \/ Proof of ownership for the item lost<\/li>\n<li>\u0e43\u0e1a\u0e41\u0e08\u0e49\u0e07\u0e04\u0e27\u0e32\u0e21 \u0e2b\u0e23\u0e37\u0e2d\u0e08\u0e14\u0e2b\u0e21\u0e32\u0e22\u0e08\u0e32\u0e01\u0e02\u0e19\u0e2a\u0e48\u0e07\u0e2a\u0e32\u0e18\u0e32\u0e23\u0e13\u0e30 \/ Police report or Letter from carrier<\/li>\n<\/ul>\n<\/div><\/div><div id=\"field_1_117\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_117\"><h3> \u0e42\u0e1b\u0e23\u0e14\u0e40\u0e15\u0e23\u0e35\u0e22\u0e21\u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e01\u0e32\u0e23\u0e40\u0e04\u0e25\u0e21\u0e43\u0e2b\u0e49\u0e04\u0e23\u0e1a\u0e16\u0e49\u0e27\u0e19 \/ Please prepare the required document<\/h3>\n<div id=\"lost-baggage\">\n<ul>\n<li>\u0e2a\u0e33\u0e40\u0e19\u0e32\u0e2b\u0e19\u0e31\u0e07\u0e2a\u0e37\u0e2d\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07  \/ Certified Copy Of Passport<\/li>\n<li>\u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e01\u0e32\u0e23\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07 \u0e2b\u0e23\u0e37\u0e2d\u0e15\u0e31\u0e4b\u0e27\u0e42\u0e14\u0e22\u0e2a\u0e32\u0e23\u0e40\u0e04\u0e23\u0e37\u0e48\u0e2d\u0e07\u0e1a\u0e34\u0e19 \/ Traveling document or E-ticket or Boarding Pass<\/li>\n<li>\u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e2d\u0e37\u0e48\u0e19\u0e46 \u0e17\u0e35\u0e48\u0e40\u0e01\u0e35\u0e48\u0e22\u0e27\u0e02\u0e49\u0e2d\u0e07 \/ Other related documents<\/li>\n<\/ul>\n<\/div><\/div><div id=\"field_1_125\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_125\"><h3> \u0e42\u0e1b\u0e23\u0e14\u0e40\u0e15\u0e23\u0e35\u0e22\u0e21\u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e01\u0e32\u0e23\u0e40\u0e04\u0e25\u0e21\u0e43\u0e2b\u0e49\u0e04\u0e23\u0e1a\u0e16\u0e49\u0e27\u0e19 \/ Please prepare the required document<\/h3>\n<div id=\"baggage-damage\">\n<ul>\n<li>\u0e2a\u0e33\u0e40\u0e19\u0e32\u0e2b\u0e19\u0e31\u0e07\u0e2a\u0e37\u0e2d\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07  \/ Certified Copy Of Passport<\/li>\n<li>\u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e01\u0e32\u0e23\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07 \u0e2b\u0e23\u0e37\u0e2d\u0e15\u0e31\u0e4b\u0e27\u0e42\u0e14\u0e22\u0e2a\u0e32\u0e23\u0e40\u0e04\u0e23\u0e37\u0e48\u0e2d\u0e07\u0e1a\u0e34\u0e19 \/ Traveling document or E-ticket or Boarding Pass<\/li>\n<li>\u0e2a\u0e33\u0e40\u0e19\u0e32\u0e2a\u0e21\u0e38\u0e14\u0e1a\u0e31\u0e0d\u0e0a\u0e35\u0e18\u0e19\u0e32\u0e04\u0e32\u0e23\u0e17\u0e35\u0e48\u0e2d\u0e2d\u0e01\u0e42\u0e14\u0e22\u0e18\u0e19\u0e32\u0e04\u0e32\u0e23\u0e43\u0e19\u0e1b\u0e23\u0e30\u0e40\u0e17\u0e28\u0e44\u0e17\u0e22 \/ A copy of bank passbook issued in Thailand<\/li>\n<li>PIR \u0e2b\u0e23\u0e37\u0e2d\u0e08\u0e14\u0e2b\u0e21\u0e32\u0e22\u0e23\u0e31\u0e1a\u0e23\u0e2d\u0e07\u0e04\u0e27\u0e32\u0e21\u0e40\u0e2a\u0e35\u0e22\u0e2b\u0e32\u0e22\u0e2d\u0e22\u0e48\u0e32\u0e07\u0e40\u0e1b\u0e47\u0e19\u0e17\u0e32\u0e07\u0e01\u0e32\u0e23\u0e08\u0e32\u0e01\u0e1c\u0e39\u0e49\u0e43\u0e2b\u0e49\u0e1a\u0e23\u0e34\u0e01\u0e32\u0e23* \/ PIR or official letter certifying the damage from provider<\/li>\n<li>\u0e23\u0e39\u0e1b\u0e20\u0e32\u0e1e\u0e17\u0e35\u0e48\u0e41\u0e2a\u0e14\u0e07\u0e04\u0e27\u0e32\u0e21\u0e40\u0e2a\u0e35\u0e22\u0e2b\u0e32\u0e22\u0e17\u0e35\u0e48\u0e40\u0e01\u0e34\u0e14\u0e02\u0e36\u0e49\u0e19 \/ Pictures showing the extent of damage.<\/li>\n<li>\u0e43\u0e1a\u0e40\u0e2a\u0e19\u0e2d\u0e23\u0e32\u0e04\u0e32\u0e04\u0e48\u0e32\u0e0b\u0e48\u0e2d\u0e21\u0e2b\u0e23\u0e37\u0e2d\u0e43\u0e1a\u0e40\u0e2a\u0e23\u0e47\u0e08\u0e04\u0e48\u0e32\u0e0b\u0e48\u0e2d\u0e21 (\u0e16\u0e49\u0e32\u0e21\u0e35) \/ Repair quote or receipt, if any.<\/li>\n<\/ul>\n<div style=\"margin-top: 30px;\">\n<p><strong>\u0e04\u0e48\u0e32\u0e40\u0e2a\u0e37\u0e48\u0e2d\u0e21\u0e23\u0e32\u0e04\u0e32<\/strong> \u0e2b\u0e21\u0e32\u0e22\u0e16\u0e36\u0e07 \u0e01\u0e32\u0e23\u0e25\u0e14\u0e25\u0e07\u0e02\u0e2d\u0e07\u0e21\u0e39\u0e25\u0e04\u0e48\u0e32\u0e17\u0e23\u0e31\u0e1e\u0e22\u0e4c\u0e2a\u0e34\u0e19\u0e40\u0e21\u0e37\u0e48\u0e2d\u0e40\u0e27\u0e25\u0e32\u0e1c\u0e48\u0e32\u0e19\u0e44\u0e1b \u0e42\u0e14\u0e22\u0e2d\u0e31\u0e15\u0e23\u0e32\u0e08\u0e30\u0e02\u0e36\u0e49\u0e19\u0e2d\u0e22\u0e39\u0e48\u0e01\u0e31\u0e1a\u0e1b\u0e35\u0e17\u0e35\u0e48\u0e0b\u0e37\u0e49\u0e2d \u0e41\u0e25\u0e30\u0e08\u0e30\u0e16\u0e39\u0e01\u0e19\u0e33\u0e21\u0e32\u0e04\u0e33\u0e19\u0e27\u0e13\u0e2b\u0e32\u0e01\u0e44\u0e21\u0e48\u0e2a\u0e32\u0e21\u0e32\u0e23\u0e16\u0e0b\u0e48\u0e2d\u0e21\u0e41\u0e0b\u0e21\u0e44\u0e14\u0e49 \/ <strong>Depreciation<\/strong> means a reduction in the value of an asset over time. The rate varies depending on the year of purchase and will apply to the item correspondingly in case repair is impossible.<\/p>\n<table>\n  <tr style=\"background: #007ab3; color: #ffffff; text-align: center;\">\n    <th>\u0e2d\u0e32\u0e22\u0e38\u0e02\u0e2d\u0e07\u0e17\u0e23\u0e31\u0e1e\u0e22\u0e4c\u0e2a\u0e34\u0e19 \/ Asset Age<\/th>\n    <th>\u0e40\u0e1b\u0e2d\u0e23\u0e4c\u0e40\u0e0b\u0e47\u0e19\u0e15\u0e4c\u0e04\u0e48\u0e32\u0e40\u0e2a\u0e37\u0e48\u0e2d\u0e21\u0e23\u0e32\u0e04\u0e32 \/ Depreciation Percentage<\/th>\n  <\/tr>\n  <tr>\n    <td>1-2 \u0e1b\u0e35<br>(1-2 years)<\/td>\n    <td>\u0e25\u0e14\u0e25\u0e07 20% \u0e02\u0e2d\u0e07\u0e21\u0e39\u0e25\u0e04\u0e48\u0e32\u0e17\u0e23\u0e31\u0e1e\u0e22\u0e4c\u0e2a\u0e34\u0e19<br>(20% depreciation of the asset value)<\/td>\n  <\/tr>\n  <tr>\n    <td>3 \u0e1b\u0e35<br>(3 years)<\/td>\n    <td>\u0e25\u0e14\u0e25\u0e07 40% \u0e02\u0e2d\u0e07\u0e21\u0e39\u0e25\u0e04\u0e48\u0e32\u0e17\u0e23\u0e31\u0e1e\u0e22\u0e4c\u0e2a\u0e34\u0e19<br>(40% depreciation of the asset value)<\/td>\n  <\/tr>\n<tr>\n    <td>4 \u0e1b\u0e35<br>(4 years)<\/td>\n    <td>\u0e25\u0e14\u0e25\u0e07 60% \u0e02\u0e2d\u0e07\u0e21\u0e39\u0e25\u0e04\u0e48\u0e32\u0e17\u0e23\u0e31\u0e1e\u0e22\u0e4c\u0e2a\u0e34\u0e19<br>(60% depreciation of the asset value)<\/td>\n  <\/tr>\n<tr>\n    <td>5 \u0e1b\u0e35<br>(5 years)<\/td>\n    <td>\u0e25\u0e14\u0e25\u0e07 80% \u0e02\u0e2d\u0e07\u0e21\u0e39\u0e25\u0e04\u0e48\u0e32\u0e17\u0e23\u0e31\u0e1e\u0e22\u0e4c\u0e2a\u0e34\u0e19<br>(80% depreciation of the asset value)<\/td>\n  <\/tr>\n<tr>\n    <td>\u0e21\u0e32\u0e01\u0e01\u0e27\u0e48\u0e32 5 \u0e1b\u0e35<br>(Over 5 years)<\/td>\n    <td>\u0e25\u0e14\u0e25\u0e07 90% \u0e02\u0e2d\u0e07\u0e21\u0e39\u0e25\u0e04\u0e48\u0e32\u0e17\u0e23\u0e31\u0e1e\u0e22\u0e4c\u0e2a\u0e34\u0e19<br>(90% depreciation of the asset value)<\/td>\n  <\/tr>\n<\/table>\n<p style=\"margin-bottom: 40px;\">*\u0e2d\u0e49\u0e32\u0e07\u0e2d\u0e34\u0e07\u0e15\u0e32\u0e21\u0e1e\u0e23\u0e30\u0e23\u0e32\u0e0a\u0e01\u0e24\u0e29\u0e0e\u0e35\u0e01\u0e32\u0e02\u0e2d\u0e07\u0e01\u0e23\u0e21\u0e2a\u0e23\u0e23\u0e1e\u0e32\u0e01\u0e23\u0e17\u0e35\u0e48 145\/2527 \u0e2a\u0e32\u0e21\u0e32\u0e23\u0e16\u0e14\u0e39\u0e23\u0e32\u0e22\u0e25\u0e30\u0e40\u0e2d\u0e35\u0e22\u0e14\u0e40\u0e1e\u0e34\u0e48\u0e21\u0e40\u0e15\u0e34\u0e21\u0e44\u0e14\u0e49\u0e17\u0e35\u0e48 <a href=\"https:\/\/www.rd.go.th\/2369.html\" target=\"_blank\">https:\/\/www.rd.go.th\/2369.html<\/a> \/ *According to The Revenue Department decree 145\/2527 at <a href=\"https:\/\/www.rd.go.th\/2369.html\" target=\"_blank\">https:\/\/www.rd.go.th\/2369.html<\/a><\/p>\n<\/div>\n<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_1_105' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_2' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_2' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_1_14\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_14\"><h3 class=\"gsection_title\">2. \u0e23\u0e32\u0e22\u0e25\u0e30\u0e40\u0e2d\u0e35\u0e22\u0e14\u0e17\u0e31\u0e48\u0e27\u0e44\u0e1b \/ GENERAL INFORMATION<\/h3><\/div><div id=\"field_1_15\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_15\"><label class='gfield_label gform-field-label' for='input_1_15' >\u0e40\u0e25\u0e02\u0e17\u0e35\u0e48\u0e01\u0e23\u0e21\u0e18\u0e23\u0e23\u0e21\u0e4c \/ Policy Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_1_15' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_16\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_16\"><label class='gfield_label gform-field-label' for='input_1_16' >\u0e0a\u0e37\u0e48\u0e2d-\u0e2a\u0e01\u0e38\u0e25 \/ First Name-Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_1_16' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_17\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_17\"><label class='gfield_label gform-field-label' for='input_1_17' >\u0e2b\u0e21\u0e32\u0e22\u0e40\u0e25\u0e02\u0e42\u0e17\u0e23\u0e28\u0e31\u0e1e\u0e17\u0e4c \/ Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_1_17' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_19\"  class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_19\"><label class='gfield_label gform-field-label' for='input_1_19' >\u0e2d\u0e35\u0e40\u0e21\u0e25 \/ Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_19' id='input_1_19' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_20\"  class=\"gfield gfield--type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_20\"><label class='gfield_label gform-field-label' for='gform_browse_button_1_20' >\u0e15\u0e31\u0e4b\u0e27\u0e42\u0e14\u0e22\u0e2a\u0e32\u0e23 \/ E-Ticket<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_1_20' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_1_20&quot;,&quot;container&quot;:&quot;gform_multifile_upload_1_20&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_1_20&quot;,&quot;filelist&quot;:&quot;gform_preview_1_20&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/?gf_page=1005716fe3bdff0&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,jpeg&quot;}],&quot;max_file_size&quot;:&quot;10485760b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:1,&quot;field_id&quot;:20},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_1_20&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_1_20' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_1_20' class='button gform_button_select_files' aria-describedby=\"gfield_upload_rules_1_20\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_20'>Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 10 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_1_20'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_1_20' class='ginput_preview_list'><\/div><\/div><div id=\"field_1_109\"  class=\"gfield gfield--type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_109\"><label class='gfield_label gform-field-label' for='gform_browse_button_1_109' >\u0e2a\u0e33\u0e40\u0e19\u0e32\u0e2b\u0e19\u0e31\u0e07\u0e2a\u0e37\u0e2d\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07 \/ Certified Copy Of Passport<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_1_109' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_1_109&quot;,&quot;container&quot;:&quot;gform_multifile_upload_1_109&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_1_109&quot;,&quot;filelist&quot;:&quot;gform_preview_1_109&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/?gf_page=1005716fe3bdff0&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,jpeg&quot;}],&quot;max_file_size&quot;:&quot;5242880b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:1,&quot;field_id&quot;:109},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_1_109&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_1_109' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_1_109' class='button gform_button_select_files' aria-describedby=\"gfield_upload_rules_1_109\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_109'>Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 5 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_1_109'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_1_109' class='ginput_preview_list'><\/div><\/div><div id=\"field_1_22\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_22\"><label class='gfield_label gform-field-label' for='input_1_22' >\u0e1b\u0e23\u0e30\u0e40\u0e17\u0e28\u0e17\u0e35\u0e48\u0e40\u0e01\u0e34\u0e14\u0e40\u0e2b\u0e15\u0e38 \/ Incident Country<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_22' id='input_1_22' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='\u0e01\u0e23\u0e38\u0e13\u0e32\u0e40\u0e25\u0e37\u0e2d\u0e01\u0e1b\u0e23\u0e30\u0e40\u0e17\u0e28\u0e17\u0e35\u0e48\u0e40\u0e01\u0e34\u0e14\u0e40\u0e2b\u0e15\u0e38' >\u0e01\u0e23\u0e38\u0e13\u0e32\u0e40\u0e25\u0e37\u0e2d\u0e01\u0e1b\u0e23\u0e30\u0e40\u0e17\u0e28\u0e17\u0e35\u0e48\u0e40\u0e01\u0e34\u0e14\u0e40\u0e2b\u0e15\u0e38<\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard and McDonald Islands' >Heard and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macau' >Macau<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Korea' >North Korea<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena' >Saint Helena<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia' >South Georgia<\/option><option value='South Korea' >South Korea<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select><\/div><\/div><div id=\"field_1_23\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_23\"><label class='gfield_label gform-field-label' for='input_1_23' >\u0e27\u0e31\u0e19\u0e17\u0e35\u0e48\u0e40\u0e01\u0e34\u0e14\u0e40\u0e2b\u0e15\u0e38 \/ Incident Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_23' id='input_1_23' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_23_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_23_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_23' class='gform_hidden' value='https:\/\/allianz-assistance.co.th\/travel\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_104' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"1\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"1\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_104' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_3' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_3' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_1_24\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_24\"><h3 class=\"gsection_title\">3. \u0e23\u0e32\u0e22\u0e25\u0e30\u0e40\u0e2d\u0e35\u0e22\u0e14\u0e01\u0e32\u0e23\u0e40\u0e23\u0e35\u0e22\u0e01\u0e23\u0e49\u0e2d\u0e07\u0e2a\u0e34\u0e19\u0e44\u0e2b\u0e21 \/ CLAIM INFORMATION<\/h3><\/div><div id=\"field_1_25\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_25\"><label class='gfield_label gform-field-label' for='input_1_25' >\u0e0a\u0e37\u0e48\u0e2d\u0e2a\u0e16\u0e32\u0e19\u0e1e\u0e22\u0e32\u0e1a\u0e32\u0e25 \/ Hospital Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_1_25' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_26\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_26\"><label class='gfield_label gform-field-label' for='input_1_26' >\u0e2d\u0e32\u0e01\u0e32\u0e23\u0e17\u0e35\u0e48\u0e17\u0e33\u0e43\u0e2b\u0e49\u0e15\u0e49\u0e2d\u0e07\u0e1e\u0e1a\u0e41\u0e1e\u0e17\u0e22\u0e4c \/ Chief Complaint<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_1_26' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_108\"  class=\"gfield gfield--type-list gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_108\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >\u0e23\u0e32\u0e22\u0e01\u0e32\u0e23\u0e04\u0e48\u0e32\u0e43\u0e0a\u0e49\u0e08\u0e48\u0e32\u0e22\u0e08\u0e32\u0e01\u0e01\u0e32\u0e23\u0e23\u0e31\u0e01\u0e29\u0e32\u0e1e\u0e22\u0e32\u0e1a\u0e32\u0e25 \/ Medical Expenses List<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">\u0e23\u0e32\u0e22\u0e01\u0e32\u0e23\u0e23\u0e31\u0e01\u0e29\u0e32\u0e1e\u0e22\u0e32\u0e1a\u0e32\u0e25 \/ Medical Treatments<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">\u0e22\u0e2d\u0e14\u0e04\u0e48\u0e32\u0e23\u0e31\u0e01\u0e29\u0e32\u0e1e\u0e22\u0e32\u0e1a\u0e32\u0e25 \/ Total Medical Expense<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_108_cell1 gform-grid-col' data-label='\u0e23\u0e32\u0e22\u0e01\u0e32\u0e23\u0e23\u0e31\u0e01\u0e29\u0e32\u0e1e\u0e22\u0e32\u0e1a\u0e32\u0e25 \/ Medical Treatments'><input aria-invalid='false' aria-required=\"true\"  aria-label='\u0e23\u0e32\u0e22\u0e01\u0e32\u0e23\u0e23\u0e31\u0e01\u0e29\u0e32\u0e1e\u0e22\u0e32\u0e1a\u0e32\u0e25 \/ Medical Treatments, Row 1' data-aria-label-template='\u0e23\u0e32\u0e22\u0e01\u0e32\u0e23\u0e23\u0e31\u0e01\u0e29\u0e32\u0e1e\u0e22\u0e32\u0e1a\u0e32\u0e25 \/ Medical Treatments, Row {0}' type='text' name='input_108[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_108_cell2 gform-grid-col' data-label='\u0e22\u0e2d\u0e14\u0e04\u0e48\u0e32\u0e23\u0e31\u0e01\u0e29\u0e32\u0e1e\u0e22\u0e32\u0e1a\u0e32\u0e25 \/ Total Medical Expense'><input aria-invalid='false' aria-required=\"true\"  aria-label='\u0e22\u0e2d\u0e14\u0e04\u0e48\u0e32\u0e23\u0e31\u0e01\u0e29\u0e32\u0e1e\u0e22\u0e32\u0e1a\u0e32\u0e25 \/ Total Medical Expense, Row 1' data-aria-label-template='\u0e22\u0e2d\u0e14\u0e04\u0e48\u0e32\u0e23\u0e31\u0e01\u0e29\u0e32\u0e1e\u0e22\u0e32\u0e1a\u0e32\u0e25 \/ Total Medical Expense, Row {0}' type='text' name='input_108[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_108_cell3 gform-grid-col' data-label='\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency'><input aria-invalid='false' aria-required=\"true\"  aria-label='\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency, Row 1' data-aria-label-template='\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency, Row {0}' type='text' name='input_108[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_1_29\"  class=\"gfield gfield--type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_29\"><label class='gfield_label gform-field-label' for='gform_browse_button_1_29' >\u0e43\u0e1a\u0e23\u0e31\u0e1a\u0e23\u0e2d\u0e07\u0e41\u0e1e\u0e17\u0e22\u0e4c \/ Physician&#039;s report describing significant symptoms<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_1_29' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_1_29&quot;,&quot;container&quot;:&quot;gform_multifile_upload_1_29&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_1_29&quot;,&quot;filelist&quot;:&quot;gform_preview_1_29&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/?gf_page=1005716fe3bdff0&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,jpeg&quot;}],&quot;max_file_size&quot;:&quot;10485760b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:1,&quot;field_id&quot;:29},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_1_29&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_1_29' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_1_29' class='button gform_button_select_files' aria-describedby=\"gfield_upload_rules_1_29\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_29'>Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 10 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_1_29'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_1_29' class='ginput_preview_list'><\/div><\/div><div id=\"field_1_30\"  class=\"gfield gfield--type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_30\"><label class='gfield_label gform-field-label' for='gform_browse_button_1_30' >\u0e43\u0e1a\u0e40\u0e2a\u0e23\u0e47\u0e08\u0e04\u0e48\u0e32\u0e23\u0e31\u0e01\u0e29\u0e32\u0e1e\u0e22\u0e32\u0e1a\u0e32\u0e25 \/ Medical Receipt or Invoice<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_1_30' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_1_30&quot;,&quot;container&quot;:&quot;gform_multifile_upload_1_30&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_1_30&quot;,&quot;filelist&quot;:&quot;gform_preview_1_30&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/?gf_page=1005716fe3bdff0&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,jpeg&quot;}],&quot;max_file_size&quot;:&quot;10485760b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:1,&quot;field_id&quot;:30},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_1_30&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_1_30' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_1_30' class='button gform_button_select_files' aria-describedby=\"gfield_upload_rules_1_30\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_30'>Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 10 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_1_30'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_1_30' class='ginput_preview_list'><\/div><\/div><div id=\"field_1_113\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_113\"><label class='gfield_label gform-field-label' for='input_1_113' >\u0e17\u0e48\u0e32\u0e19\u0e21\u0e35\u0e42\u0e23\u0e04\u0e1b\u0e23\u0e30\u0e08\u0e33\u0e15\u0e31\u0e27\u0e2b\u0e23\u0e37\u0e2d\u0e23\u0e31\u0e1a\u0e1b\u0e23\u0e30\u0e17\u0e32\u0e19\u0e22\u0e32\u0e40\u0e1b\u0e47\u0e19\u0e1b\u0e23\u0e30\u0e08\u0e33\u0e2b\u0e23\u0e37\u0e2d\u0e44\u0e21\u0e48 (\u0e42\u0e1b\u0e23\u0e14\u0e23\u0e30\u0e1a\u0e38 \u0e16\u0e49\u0e32\u0e21\u0e35) \/ Do you have any medical condition or take any medicine regularly? (Please specify if any)<\/label><div class='ginput_container ginput_container_text'><input name='input_113' id='input_1_113' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_114\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_114\"><label class='gfield_label gform-field-label' for='input_1_114' >\u0e17\u0e48\u0e32\u0e19\u0e17\u0e33\u0e01\u0e32\u0e23\u0e23\u0e31\u0e01\u0e29\u0e32\u0e2b\u0e23\u0e37\u0e2d\u0e1e\u0e1a\u0e41\u0e1e\u0e17\u0e22\u0e4c\u0e40\u0e1b\u0e47\u0e19\u0e1b\u0e23\u0e30\u0e08\u0e33\u0e17\u0e35\u0e48\u0e43\u0e14 (\u0e42\u0e1b\u0e23\u0e14\u0e23\u0e30\u0e1a\u0e38 \u0e16\u0e49\u0e32\u0e21\u0e35) \/ Where do you get treatment or see your doctor regularly? (Please specify if any)<\/label><div class='ginput_container ginput_container_text'><input name='input_114' id='input_1_114' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_115\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_115\"><legend class='gfield_label gform-field-label'  >\u0e17\u0e48\u0e32\u0e19\u0e40\u0e04\u0e22\u0e21\u0e35\u0e2d\u0e32\u0e01\u0e32\u0e23\u0e40\u0e08\u0e47\u0e1a\u0e1b\u0e48\u0e27\u0e22\u0e41\u0e1a\u0e1a\u0e40\u0e14\u0e35\u0e22\u0e27\u0e01\u0e31\u0e1a\u0e17\u0e35\u0e48\u0e17\u0e48\u0e32\u0e19\u0e40\u0e23\u0e35\u0e22\u0e01\u0e23\u0e49\u0e2d\u0e07\u0e04\u0e48\u0e32\u0e2a\u0e34\u0e19\u0e44\u0e2b\u0e21\u0e21\u0e32\u0e01\u0e48\u0e2d\u0e19\u0e2b\u0e23\u0e37\u0e2d\u0e44\u0e21\u0e48 \/ Have you ever have the symptoms the same as you request the claim?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_115'>\n\t\t\t<div class='gchoice gchoice_1_115_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_115' type='radio' value='\u0e40\u0e04\u0e22'  id='choice_1_115_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_115_0' id='label_1_115_0' class='gform-field-label gform-field-label--type-inline'>\u0e40\u0e04\u0e22<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_115_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_115' type='radio' value='\u0e44\u0e21\u0e48\u0e40\u0e04\u0e22'  id='choice_1_115_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_115_1' id='label_1_115_1' class='gform-field-label gform-field-label--type-inline'>\u0e44\u0e21\u0e48\u0e40\u0e04\u0e22<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_116\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_116\"><label class='gfield_label gform-field-label' for='input_1_116' >\u0e2b\u0e32\u0e01\u0e40\u0e04\u0e22\u0e21\u0e35\u0e2d\u0e32\u0e01\u0e32\u0e23\u0e19\u0e35\u0e49 \u0e17\u0e48\u0e32\u0e19\u0e1e\u0e1a\u0e41\u0e1e\u0e17\u0e22\u0e4c\u0e41\u0e25\u0e30\u0e23\u0e31\u0e1a\u0e22\u0e32\u0e1b\u0e23\u0e30\u0e08\u0e33\u0e17\u0e35\u0e48\u0e2a\u0e16\u0e32\u0e19\u0e1e\u0e22\u0e32\u0e1a\u0e32\u0e25\u0e43\u0e14 \/ If you ever have, where did you get the treatment and see the doctor?<\/label><div class='ginput_container ginput_container_text'><input name='input_116' id='input_1_116' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_31\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_31\"><label class='gfield_label gform-field-label' for='input_1_31' >\u0e40\u0e17\u0e35\u0e48\u0e22\u0e27\u0e1a\u0e34\u0e19\u0e17\u0e35\u0e48\u0e40\u0e01\u0e34\u0e14\u0e01\u0e32\u0e23\u0e25\u0e48\u0e32\u0e0a\u0e49\u0e32 \/ Initial flight\/travel delay which delayed\/canceled<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_1_31' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_33\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_33\"><label class='gfield_label gform-field-label' for='input_1_33' >\u0e27\u0e31\u0e19\u0e17\u0e35\u0e48\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07\u0e16\u0e36\u0e07\u0e15\u0e32\u0e21\u0e01\u0e33\u0e2b\u0e19\u0e14\u0e01\u0e32\u0e23 \/ Scheduled date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_33' id='input_1_33' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_33_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_33_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_33' class='gform_hidden' value='https:\/\/allianz-assistance.co.th\/travel\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_1_34\"  class=\"gfield gfield--type-time gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_34\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >\u0e40\u0e27\u0e25\u0e32\u0e17\u0e35\u0e48\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07\u0e16\u0e36\u0e07\u0e15\u0e32\u0e21\u0e01\u0e33\u0e2b\u0e19\u0e14\u0e01\u0e32\u0e23 \/ Scheduled time<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class=\"ginput_container ginput_complex gform-grid-row\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_1_34'>\n                            <input type='text' maxlength='2' name='input_34[]' id='input_1_34_1' value=''    placeholder='HH' aria-required='true'   \/> \n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_1_34_1'>Hours<\/label>\n                        <\/div>\n                        <div class=\"below hour_minute_colon gform-grid-col\">:<\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='text' maxlength='2' name='input_34[]' id='input_1_34_2' value=''    placeholder='MM' aria-required='true'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_1_34_2'>Minutes<\/label>\n                        <\/div>\n                        \n                    <\/div><\/fieldset><div id=\"field_1_35\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_35\"><label class='gfield_label gform-field-label' for='input_1_35' >\u0e27\u0e31\u0e19\u0e17\u0e35\u0e48\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07\u0e16\u0e36\u0e07\u0e08\u0e23\u0e34\u0e07 \/ Actual arrival date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_35' id='input_1_35' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_35_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_35_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_35' class='gform_hidden' value='https:\/\/allianz-assistance.co.th\/travel\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_1_36\"  class=\"gfield gfield--type-time gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_36\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >\u0e40\u0e27\u0e25\u0e32\u0e17\u0e35\u0e48\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07\u0e16\u0e36\u0e07\u0e08\u0e23\u0e34\u0e07 \/ Actual arrival time<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class=\"ginput_container ginput_complex gform-grid-row\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_1_36'>\n                            <input type='text' maxlength='2' name='input_36[]' id='input_1_36_1' value=''    placeholder='HH' aria-required='true'   \/> \n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_1_36_1'>Hours<\/label>\n                        <\/div>\n                        <div class=\"below hour_minute_colon gform-grid-col\">:<\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='text' maxlength='2' name='input_36[]' id='input_1_36_2' value=''    placeholder='MM' aria-required='true'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_1_36_2'>Minutes<\/label>\n                        <\/div>\n                        \n                    <\/div><\/fieldset><div id=\"field_1_37\"  class=\"gfield gfield--type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_37\"><label class='gfield_label gform-field-label' for='input_1_37' >\u0e08\u0e33\u0e19\u0e27\u0e19\u0e0a\u0e31\u0e48\u0e27\u0e42\u0e21\u0e07\u0e17\u0e35\u0e48\u0e25\u0e48\u0e32\u0e0a\u0e49\u0e32 \/ Number of delayed hours<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_37' id='input_1_37' type='text'    value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_1_37\" \/><div class='gfield_description instruction ' id='gfield_instruction_1_37'>Please enter a number from <strong>1<\/strong> to <strong>100<\/strong>.<\/div><\/div><\/div><div id=\"field_1_38\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_38\"><label class='gfield_label gform-field-label' for='input_1_38' >\u0e2a\u0e32\u0e40\u0e2b\u0e15\u0e38\u0e02\u0e2d\u0e07\u0e01\u0e32\u0e23\u0e25\u0e48\u0e32\u0e0a\u0e49\u0e32 \/ Reason of Flight \/ Travel Delay<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_38' id='input_1_38' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='\u0e01\u0e23\u0e38\u0e13\u0e32\u0e40\u0e25\u0e37\u0e2d\u0e01\u0e2a\u0e32\u0e40\u0e2b\u0e15\u0e38\u0e02\u0e2d\u0e07\u0e01\u0e32\u0e23\u0e25\u0e48\u0e32\u0e0a\u0e49\u0e32' >\u0e01\u0e23\u0e38\u0e13\u0e32\u0e40\u0e25\u0e37\u0e2d\u0e01\u0e2a\u0e32\u0e40\u0e2b\u0e15\u0e38\u0e02\u0e2d\u0e07\u0e01\u0e32\u0e23\u0e25\u0e48\u0e32\u0e0a\u0e49\u0e32<\/option><option value='\u0e1b\u0e31\u0e0d\u0e2b\u0e32\u0e17\u0e32\u0e07\u0e40\u0e17\u0e04\u0e19\u0e34\u0e04 \/ Aircraft Technical or Mechanical problem' >\u0e1b\u0e31\u0e0d\u0e2b\u0e32\u0e17\u0e32\u0e07\u0e40\u0e17\u0e04\u0e19\u0e34\u0e04 \/ Aircraft Technical or Mechanical problem<\/option><option value='\u0e2a\u0e20\u0e32\u0e1e\u0e2d\u0e32\u0e01\u0e32\u0e28 \/ Bad weather' >\u0e2a\u0e20\u0e32\u0e1e\u0e2d\u0e32\u0e01\u0e32\u0e28 \/ Bad weather<\/option><option value='\u0e2d\u0e37\u0e48\u0e19\u0e46 \/ Other' >\u0e2d\u0e37\u0e48\u0e19\u0e46 \/ Other<\/option><\/select><\/div><\/div><div id=\"field_1_39\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_39\"><label class='gfield_label gform-field-label' for='input_1_39' >\u0e42\u0e1b\u0e23\u0e14\u0e23\u0e30\u0e1a\u0e38 \/ Please specify<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_1_39' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_42\"  class=\"gfield gfield--type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_42\"><label class='gfield_label gform-field-label' for='gform_browse_button_1_42' >\u0e08\u0e14\u0e2b\u0e21\u0e32\u0e22\u0e08\u0e32\u0e01\u0e02\u0e19\u0e2a\u0e48\u0e07\u0e41\u0e08\u0e49\u0e07\u0e2a\u0e32\u0e40\u0e2b\u0e15\u0e38\u0e01\u0e32\u0e23\u0e25\u0e48\u0e32\u0e0a\u0e49\u0e32 \/ Letter from carrier detailing the reason<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_1_42' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_1_42&quot;,&quot;container&quot;:&quot;gform_multifile_upload_1_42&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_1_42&quot;,&quot;filelist&quot;:&quot;gform_preview_1_42&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/?gf_page=1005716fe3bdff0&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,jpeg&quot;}],&quot;max_file_size&quot;:&quot;10485760b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:1,&quot;field_id&quot;:42},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_1_42&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_1_42' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_1_42' class='button gform_button_select_files' aria-describedby=\"gfield_upload_rules_1_42\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_42'>Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 10 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_1_42'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_1_42' class='ginput_preview_list'><\/div><\/div><div id=\"field_1_43\"  class=\"gfield gfield--type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_43\"><label class='gfield_label gform-field-label' for='gform_browse_button_1_43' >\u0e1a\u0e2d\u0e23\u0e4c\u0e14\u0e14\u0e34\u0e49\u0e07\u0e1e\u0e32\u0e2a\u0e02\u0e2d\u0e07\u0e40\u0e17\u0e35\u0e48\u0e22\u0e27\u0e1a\u0e34\u0e19\u0e17\u0e35\u0e48\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07\u0e08\u0e23\u0e34\u0e07 \/ Boarding pass of actual flights<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_1_43' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_1_43&quot;,&quot;container&quot;:&quot;gform_multifile_upload_1_43&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_1_43&quot;,&quot;filelist&quot;:&quot;gform_preview_1_43&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/?gf_page=1005716fe3bdff0&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,jpeg&quot;}],&quot;max_file_size&quot;:&quot;10485760b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:1,&quot;field_id&quot;:43},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_1_43&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_1_43' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_1_43' class='button gform_button_select_files' aria-describedby=\"gfield_upload_rules_1_43\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_43'>Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 10 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_1_43'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_1_43' class='ginput_preview_list'><\/div><\/div><div id=\"field_1_45\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_45\"><label class='gfield_label gform-field-label' for='input_1_45' >\u0e40\u0e17\u0e35\u0e48\u0e22\u0e27\u0e1a\u0e34\u0e19\u0e17\u0e35\u0e48\u0e40\u0e01\u0e34\u0e14\u0e01\u0e32\u0e23\u0e25\u0e48\u0e32\u0e0a\u0e49\u0e32 \/\u0e22\u0e01\u0e40\u0e25\u0e34\u0e01\u0e41\u0e25\u0e30\u0e17\u0e33\u0e43\u0e2b\u0e49\u0e1e\u0e25\u0e32\u0e14\u0e40\u0e17\u0e35\u0e48\u0e22\u0e27\u0e1a\u0e34\u0e19\u0e15\u0e48\u0e2d \/ Initial flight which delayed\/canceled and lead to missing connecting flight<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_1_45' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_46\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_46\"><label class='gfield_label gform-field-label' for='input_1_46' >\u0e27\u0e31\u0e19\u0e17\u0e35\u0e48\u0e16\u0e36\u0e07\u0e2a\u0e19\u0e32\u0e21\u0e1a\u0e34\u0e19\u0e08\u0e23\u0e34\u0e07\u0e17\u0e35\u0e48\u0e17\u0e33\u0e43\u0e2b\u0e49\u0e17\u0e48\u0e32\u0e19\u0e1e\u0e25\u0e32\u0e14\u0e40\u0e17\u0e35\u0e48\u0e22\u0e27\u0e1a\u0e34\u0e19 \/ Actual arrival date of initial flight<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_46' id='input_1_46' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_46_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_46_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_46' class='gform_hidden' value='https:\/\/allianz-assistance.co.th\/travel\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_1_47\"  class=\"gfield gfield--type-time gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_47\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >\u0e40\u0e27\u0e25\u0e32\u0e08\u0e23\u0e34\u0e07\u0e17\u0e35\u0e48\u0e16\u0e36\u0e07\u0e2a\u0e19\u0e32\u0e21\u0e1a\u0e34\u0e19\u0e17\u0e35\u0e48\u0e17\u0e33\u0e43\u0e2b\u0e49\u0e17\u0e48\u0e32\u0e19\u0e1e\u0e25\u0e32\u0e14\u0e40\u0e17\u0e35\u0e48\u0e22\u0e27\u0e1a\u0e34\u0e19 \/ Actual arrival time of initial flight<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class=\"ginput_container ginput_complex gform-grid-row\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_1_47'>\n                            <input type='text' maxlength='2' name='input_47[]' id='input_1_47_1' value=''    placeholder='HH' aria-required='true'   \/> \n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_1_47_1'>Hours<\/label>\n                        <\/div>\n                        <div class=\"below hour_minute_colon gform-grid-col\">:<\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='text' maxlength='2' name='input_47[]' id='input_1_47_2' value=''    placeholder='MM' aria-required='true'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_1_47_2'>Minutes<\/label>\n                        <\/div>\n                        \n                    <\/div><\/fieldset><div id=\"field_1_48\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_48\"><label class='gfield_label gform-field-label' for='input_1_48' >\u0e2b\u0e21\u0e32\u0e22\u0e40\u0e25\u0e02\u0e40\u0e17\u0e35\u0e48\u0e22\u0e27\u0e1a\u0e34\u0e19\u0e17\u0e14\u0e41\u0e17\u0e19 \/ Departure flight number of alternative onward flight<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_1_48' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_50\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_50\"><label class='gfield_label gform-field-label' for='input_1_50' >\u0e27\u0e31\u0e19\u0e17\u0e35\u0e48\u0e2d\u0e2d\u0e01\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07\u0e08\u0e23\u0e34\u0e07\u0e02\u0e2d\u0e07\u0e40\u0e17\u0e35\u0e48\u0e22\u0e27\u0e1a\u0e34\u0e19\u0e17\u0e14\u0e41\u0e17\u0e19 \/ Actual departure date of alternative onward flight<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_50' id='input_1_50' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_50_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_50_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_50' class='gform_hidden' value='https:\/\/allianz-assistance.co.th\/travel\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_1_51\"  class=\"gfield gfield--type-time gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_51\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >\u0e40\u0e27\u0e25\u0e32\u0e2d\u0e2d\u0e01\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07\u0e08\u0e23\u0e34\u0e07\u0e02\u0e2d\u0e07\u0e40\u0e17\u0e35\u0e48\u0e22\u0e27\u0e1a\u0e34\u0e19\u0e17\u0e14\u0e41\u0e17\u0e19 \/ Actual departure time of alternative onward flight<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class=\"ginput_container ginput_complex gform-grid-row\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_1_51'>\n                            <input type='text' maxlength='2' name='input_51[]' id='input_1_51_1' value=''    placeholder='HH' aria-required='true'   \/> \n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_1_51_1'>Hours<\/label>\n                        <\/div>\n                        <div class=\"below hour_minute_colon gform-grid-col\">:<\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='text' maxlength='2' name='input_51[]' id='input_1_51_2' value=''    placeholder='MM' aria-required='true'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_1_51_2'>Minutes<\/label>\n                        <\/div>\n                        \n                    <\/div><\/fieldset><div id=\"field_1_52\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_52\"><label class='gfield_label gform-field-label' for='input_1_52' >\u0e27\u0e31\u0e19\u0e17\u0e35\u0e48\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07\u0e16\u0e36\u0e07\u0e08\u0e38\u0e14\u0e2b\u0e21\u0e32\u0e22 \/ Actual arrival date at destination<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_52' id='input_1_52' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_52_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_52_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_52' class='gform_hidden' value='https:\/\/allianz-assistance.co.th\/travel\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_1_53\"  class=\"gfield gfield--type-time gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_53\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >\u0e40\u0e27\u0e25\u0e32\u0e17\u0e35\u0e48\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07\u0e16\u0e36\u0e07\u0e08\u0e38\u0e14\u0e2b\u0e21\u0e32\u0e22 \/ Actual arrival time at destination<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class=\"ginput_container ginput_complex gform-grid-row\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_1_53'>\n                            <input type='text' maxlength='2' name='input_53[]' id='input_1_53_1' value=''    placeholder='HH' aria-required='true'   \/> \n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_1_53_1'>Hours<\/label>\n                        <\/div>\n                        <div class=\"below hour_minute_colon gform-grid-col\">:<\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='text' maxlength='2' name='input_53[]' id='input_1_53_2' value=''    placeholder='MM' aria-required='true'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_1_53_2'>Minutes<\/label>\n                        <\/div>\n                        \n                    <\/div><\/fieldset><div id=\"field_1_54\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_54\"><label class='gfield_label gform-field-label' for='input_1_54' >\u0e2a\u0e32\u0e40\u0e2b\u0e15\u0e38\u0e02\u0e2d\u0e07\u0e01\u0e32\u0e23\u0e25\u0e48\u0e32\u0e0a\u0e49\u0e32 \/ Reason of delay flight (Missed connect flight)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_54' id='input_1_54' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='\u0e01\u0e23\u0e38\u0e13\u0e32\u0e40\u0e25\u0e37\u0e2d\u0e01\u0e2a\u0e32\u0e40\u0e2b\u0e15\u0e38\u0e02\u0e2d\u0e07\u0e01\u0e32\u0e23\u0e25\u0e48\u0e32\u0e0a\u0e49\u0e32' >\u0e01\u0e23\u0e38\u0e13\u0e32\u0e40\u0e25\u0e37\u0e2d\u0e01\u0e2a\u0e32\u0e40\u0e2b\u0e15\u0e38\u0e02\u0e2d\u0e07\u0e01\u0e32\u0e23\u0e25\u0e48\u0e32\u0e0a\u0e49\u0e32<\/option><option value='\u0e1b\u0e31\u0e0d\u0e2b\u0e32\u0e17\u0e32\u0e07\u0e40\u0e17\u0e04\u0e19\u0e34\u0e04 \/ Aircraft Technical or Mechanical problem' >\u0e1b\u0e31\u0e0d\u0e2b\u0e32\u0e17\u0e32\u0e07\u0e40\u0e17\u0e04\u0e19\u0e34\u0e04 \/ Aircraft Technical or Mechanical problem<\/option><option value='\u0e2a\u0e20\u0e32\u0e1e\u0e2d\u0e32\u0e01\u0e32\u0e28 \/ Bad weather' >\u0e2a\u0e20\u0e32\u0e1e\u0e2d\u0e32\u0e01\u0e32\u0e28 \/ Bad weather<\/option><option value='\u0e2d\u0e37\u0e48\u0e19\u0e46 \/ Other' >\u0e2d\u0e37\u0e48\u0e19\u0e46 \/ Other<\/option><\/select><\/div><\/div><div id=\"field_1_55\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_55\"><label class='gfield_label gform-field-label' for='input_1_55' >\u0e42\u0e1b\u0e23\u0e14\u0e23\u0e30\u0e1a\u0e38 \/ Please specify  (Missed connect flight)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_1_55' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_57\"  class=\"gfield gfield--type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_57\"><label class='gfield_label gform-field-label' for='input_1_57' >\u0e04\u0e48\u0e32\u0e17\u0e35\u0e48\u0e1e\u0e31\u0e01\u0e40\u0e1e\u0e34\u0e48\u0e21\u0e40\u0e15\u0e34\u0e21\u0e17\u0e35\u0e48\u0e15\u0e49\u0e2d\u0e07\u0e04\u0e49\u0e32\u0e07\u0e04\u0e37\u0e19 (\u0e16\u0e49\u0e32\u0e21\u0e35) \/ Additional overnight hotel accommodation cost (If any) (Missed connect flight)<\/label><div class='ginput_container ginput_container_number'><input name='input_57' id='input_1_57' type='text'    value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_110\"  class=\"gfield gfield--type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_110\"><label class='gfield_label gform-field-label' for='gform_browse_button_1_110' >\u0e08\u0e14\u0e2b\u0e21\u0e32\u0e22\u0e08\u0e32\u0e01\u0e02\u0e19\u0e2a\u0e48\u0e07\u0e41\u0e08\u0e49\u0e07\u0e2a\u0e32\u0e40\u0e2b\u0e15\u0e38\u0e01\u0e32\u0e23\u0e25\u0e48\u0e32\u0e0a\u0e49\u0e32 \/ Letter from carrier detailing the reason (Missed connect flight)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_1_110' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_1_110&quot;,&quot;container&quot;:&quot;gform_multifile_upload_1_110&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_1_110&quot;,&quot;filelist&quot;:&quot;gform_preview_1_110&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/?gf_page=1005716fe3bdff0&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,jpeg&quot;}],&quot;max_file_size&quot;:&quot;5242880b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:1,&quot;field_id&quot;:110},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_1_110&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_1_110' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_1_110' class='button gform_button_select_files' aria-describedby=\"gfield_upload_rules_1_110\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_110'>Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 5 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_1_110'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_1_110' class='ginput_preview_list'><\/div><\/div><div id=\"field_1_111\"  class=\"gfield gfield--type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_111\"><label class='gfield_label gform-field-label' for='gform_browse_button_1_111' >\u0e43\u0e1a\u0e40\u0e2a\u0e23\u0e47\u0e08\u0e04\u0e48\u0e32\u0e17\u0e35\u0e48\u0e1e\u0e31\u0e01\u0e40\u0e1e\u0e34\u0e48\u0e21\u0e40\u0e15\u0e34\u0e21\u0e17\u0e35\u0e48\u0e15\u0e49\u0e2d\u0e07\u0e04\u0e49\u0e32\u0e07\u0e04\u0e37\u0e19 (\u0e16\u0e49\u0e32\u0e21\u0e35) \/ Additional overnight hotel accommodation receipt (If any) (Missed connect flight)<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_1_111' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_1_111&quot;,&quot;container&quot;:&quot;gform_multifile_upload_1_111&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_1_111&quot;,&quot;filelist&quot;:&quot;gform_preview_1_111&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/?gf_page=1005716fe3bdff0&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,jpeg&quot;}],&quot;max_file_size&quot;:&quot;5242880b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:1,&quot;field_id&quot;:111},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_1_111&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_1_111' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_1_111' class='button gform_button_select_files' aria-describedby=\"gfield_upload_rules_1_111\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_111'>Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 5 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_1_111'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_1_111' class='ginput_preview_list'><\/div><\/div><div id=\"field_1_60\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_60\"><label class='gfield_label gform-field-label' for='input_1_60' >\u0e27\u0e31\u0e19\u0e17\u0e35\u0e48\u0e22\u0e01\u0e40\u0e25\u0e34\u0e01 \/ Cancellation Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_60' id='input_1_60' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_60_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_60_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_60' class='gform_hidden' value='https:\/\/allianz-assistance.co.th\/travel\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_61\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_61\"><label class='gfield_label gform-field-label' for='input_1_61' >\u0e40\u0e2b\u0e15\u0e38\u0e1c\u0e25\u0e01\u0e32\u0e23\u0e22\u0e01\u0e40\u0e25\u0e34\u0e01 \/ Reason of Cancellation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_61' id='input_1_61' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='\u0e01\u0e23\u0e38\u0e13\u0e32\u0e40\u0e25\u0e37\u0e2d\u0e01\u0e40\u0e2b\u0e15\u0e38\u0e1c\u0e25\u0e01\u0e32\u0e23\u0e22\u0e01\u0e40\u0e25\u0e34\u0e01' >\u0e01\u0e23\u0e38\u0e13\u0e32\u0e40\u0e25\u0e37\u0e2d\u0e01\u0e40\u0e2b\u0e15\u0e38\u0e1c\u0e25\u0e01\u0e32\u0e23\u0e22\u0e01\u0e40\u0e25\u0e34\u0e01<\/option><option value='\u0e01\u0e32\u0e23\u0e22\u0e01\u0e40\u0e25\u0e34\u0e01\u0e40\u0e17\u0e35\u0e48\u0e22\u0e27\u0e1a\u0e34\u0e19\u0e08\u0e32\u0e01\u0e2a\u0e32\u0e22\u0e01\u0e32\u0e23\u0e1a\u0e34\u0e19\u0e40\u0e19\u0e37\u0e48\u0e2d\u0e07\u0e08\u0e32\u0e01\u0e08\u0e25\u0e32\u0e08\u0e25\u0e1e\u0e32\u0e22\u0e38\u0e2b\u0e23\u0e37\u0e2d\u0e44\u0e15\u0e49\u0e1d\u0e38\u0e48\u0e19 \/ Cancellation of carrier due to riot, storm or tornado' >\u0e01\u0e32\u0e23\u0e22\u0e01\u0e40\u0e25\u0e34\u0e01\u0e40\u0e17\u0e35\u0e48\u0e22\u0e27\u0e1a\u0e34\u0e19\u0e08\u0e32\u0e01\u0e2a\u0e32\u0e22\u0e01\u0e32\u0e23\u0e1a\u0e34\u0e19\u0e40\u0e19\u0e37\u0e48\u0e2d\u0e07\u0e08\u0e32\u0e01\u0e08\u0e25\u0e32\u0e08\u0e25\u0e1e\u0e32\u0e22\u0e38\u0e2b\u0e23\u0e37\u0e2d\u0e44\u0e15\u0e49\u0e1d\u0e38\u0e48\u0e19 \/ Cancellation of carrier due to riot, storm or tornado<\/option><option value='\u0e01\u0e32\u0e23\u0e2a\u0e39\u0e0d\u0e40\u0e2a\u0e35\u0e22\u0e0a\u0e35\u0e27\u0e34\u0e15\u0e02\u0e2d\u0e07\u0e0d\u0e32\u0e15\u0e34 \u0e2b\u0e23\u0e37\u0e2d\u0e04\u0e39\u0e48\u0e04\u0e49\u0e32\u0e17\u0e32\u0e07\u0e18\u0e38\u0e23\u0e01\u0e34\u0e08\u0e02\u0e2d\u0e07\u0e1c\u0e39\u0e49\u0e40\u0e2d\u0e32\u0e1b\u0e23\u0e30\u0e01\u0e31\u0e19 \/ Death of closed family or business associate' >\u0e01\u0e32\u0e23\u0e2a\u0e39\u0e0d\u0e40\u0e2a\u0e35\u0e22\u0e0a\u0e35\u0e27\u0e34\u0e15\u0e02\u0e2d\u0e07\u0e0d\u0e32\u0e15\u0e34 \u0e2b\u0e23\u0e37\u0e2d\u0e04\u0e39\u0e48\u0e04\u0e49\u0e32\u0e17\u0e32\u0e07\u0e18\u0e38\u0e23\u0e01\u0e34\u0e08\u0e02\u0e2d\u0e07\u0e1c\u0e39\u0e49\u0e40\u0e2d\u0e32\u0e1b\u0e23\u0e30\u0e01\u0e31\u0e19 \/ Death of closed family or business associate<\/option><option value='\u0e01\u0e32\u0e23\u0e40\u0e08\u0e47\u0e1a\u0e1b\u0e48\u0e27\u0e22\u0e23\u0e49\u0e32\u0e22\u0e41\u0e23\u0e07\u0e02\u0e2d\u0e07\u0e1c\u0e39\u0e49\u0e40\u0e2d\u0e32\u0e1b\u0e23\u0e30\u0e01\u0e31\u0e19 \/ Serious illness of Insured person' >\u0e01\u0e32\u0e23\u0e40\u0e08\u0e47\u0e1a\u0e1b\u0e48\u0e27\u0e22\u0e23\u0e49\u0e32\u0e22\u0e41\u0e23\u0e07\u0e02\u0e2d\u0e07\u0e1c\u0e39\u0e49\u0e40\u0e2d\u0e32\u0e1b\u0e23\u0e30\u0e01\u0e31\u0e19 \/ Serious illness of Insured person<\/option><option value='\u0e01\u0e32\u0e23\u0e40\u0e08\u0e47\u0e1a\u0e1b\u0e48\u0e27\u0e22\u0e23\u0e49\u0e32\u0e22\u0e41\u0e23\u0e07\u0e02\u0e2d\u0e07\u0e0d\u0e32\u0e15\u0e34 \u0e2b\u0e23\u0e37\u0e2d\u0e04\u0e39\u0e48\u0e04\u0e49\u0e32\u0e17\u0e32\u0e07\u0e18\u0e38\u0e23\u0e01\u0e34\u0e08\u0e02\u0e2d\u0e07\u0e1c\u0e39\u0e49\u0e40\u0e2d\u0e32\u0e1b\u0e23\u0e30\u0e01\u0e31\u0e19 \/ Serious illness of closed family or business associate' >\u0e01\u0e32\u0e23\u0e40\u0e08\u0e47\u0e1a\u0e1b\u0e48\u0e27\u0e22\u0e23\u0e49\u0e32\u0e22\u0e41\u0e23\u0e07\u0e02\u0e2d\u0e07\u0e0d\u0e32\u0e15\u0e34 \u0e2b\u0e23\u0e37\u0e2d\u0e04\u0e39\u0e48\u0e04\u0e49\u0e32\u0e17\u0e32\u0e07\u0e18\u0e38\u0e23\u0e01\u0e34\u0e08\u0e02\u0e2d\u0e07\u0e1c\u0e39\u0e49\u0e40\u0e2d\u0e32\u0e1b\u0e23\u0e30\u0e01\u0e31\u0e19 \/ Serious illness of closed family or business associate<\/option><option value='\u0e2a\u0e32\u0e40\u0e2b\u0e15\u0e38\u0e01\u0e32\u0e23\u0e22\u0e01\u0e40\u0e25\u0e34\u0e01\u0e2d\u0e37\u0e48\u0e19\u0e46 \/ Others' >\u0e2a\u0e32\u0e40\u0e2b\u0e15\u0e38\u0e01\u0e32\u0e23\u0e22\u0e01\u0e40\u0e25\u0e34\u0e01\u0e2d\u0e37\u0e48\u0e19\u0e46 \/ Others<\/option><\/select><\/div><\/div><div id=\"field_1_122\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_122\"><label class='gfield_label gform-field-label' for='input_1_122' >\u0e42\u0e1b\u0e23\u0e14\u0e23\u0e30\u0e1a\u0e38 \/ Please specify<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_122' id='input_1_122' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_67\"  class=\"gfield gfield--type-list gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_67\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >\u0e23\u0e32\u0e22\u0e01\u0e32\u0e23\u0e2a\u0e34\u0e48\u0e07\u0e02\u0e2d\u0e07\u0e17\u0e35\u0e48\u0e15\u0e49\u0e2d\u0e07\u0e01\u0e32\u0e23\u0e40\u0e04\u0e25\u0e21 \/ List of claimed item<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">\u0e0a\u0e37\u0e48\u0e2d\u0e23\u0e32\u0e22\u0e01\u0e32\u0e23 \/ Name of item<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">\u0e08\u0e33\u0e19\u0e27\u0e19\u0e40\u0e07\u0e34\u0e19\u0e17\u0e35\u0e48\u0e08\u0e48\u0e32\u0e22 \/ Pre-Paid amount<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">\u0e08\u0e33\u0e19\u0e27\u0e19\u0e40\u0e07\u0e34\u0e19\u0e17\u0e35\u0e48\u0e44\u0e14\u0e49\u0e04\u0e37\u0e19 \/ Refund amount<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">\u0e08\u0e33\u0e19\u0e27\u0e19\u0e40\u0e07\u0e34\u0e19\u0e17\u0e35\u0e48\u0e44\u0e21\u0e48\u0e44\u0e14\u0e49\u0e04\u0e37\u0e19 \/ Non-refund amount<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_67_cell1 gform-grid-col' data-label='\u0e0a\u0e37\u0e48\u0e2d\u0e23\u0e32\u0e22\u0e01\u0e32\u0e23 \/ Name of item'><input aria-invalid='false' aria-required=\"true\"  aria-label='\u0e0a\u0e37\u0e48\u0e2d\u0e23\u0e32\u0e22\u0e01\u0e32\u0e23 \/ Name of item, Row 1' data-aria-label-template='\u0e0a\u0e37\u0e48\u0e2d\u0e23\u0e32\u0e22\u0e01\u0e32\u0e23 \/ Name of item, Row {0}' type='text' name='input_67[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_67_cell2 gform-grid-col' data-label='\u0e08\u0e33\u0e19\u0e27\u0e19\u0e40\u0e07\u0e34\u0e19\u0e17\u0e35\u0e48\u0e08\u0e48\u0e32\u0e22 \/ Pre-Paid amount'><input aria-invalid='false' aria-required=\"true\"  aria-label='\u0e08\u0e33\u0e19\u0e27\u0e19\u0e40\u0e07\u0e34\u0e19\u0e17\u0e35\u0e48\u0e08\u0e48\u0e32\u0e22 \/ Pre-Paid amount, Row 1' data-aria-label-template='\u0e08\u0e33\u0e19\u0e27\u0e19\u0e40\u0e07\u0e34\u0e19\u0e17\u0e35\u0e48\u0e08\u0e48\u0e32\u0e22 \/ Pre-Paid amount, Row {0}' type='text' name='input_67[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_67_cell3 gform-grid-col' data-label='\u0e08\u0e33\u0e19\u0e27\u0e19\u0e40\u0e07\u0e34\u0e19\u0e17\u0e35\u0e48\u0e44\u0e14\u0e49\u0e04\u0e37\u0e19 \/ Refund amount'><input aria-invalid='false' aria-required=\"true\"  aria-label='\u0e08\u0e33\u0e19\u0e27\u0e19\u0e40\u0e07\u0e34\u0e19\u0e17\u0e35\u0e48\u0e44\u0e14\u0e49\u0e04\u0e37\u0e19 \/ Refund amount, Row 1' data-aria-label-template='\u0e08\u0e33\u0e19\u0e27\u0e19\u0e40\u0e07\u0e34\u0e19\u0e17\u0e35\u0e48\u0e44\u0e14\u0e49\u0e04\u0e37\u0e19 \/ Refund amount, Row {0}' type='text' name='input_67[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_67_cell4 gform-grid-col' data-label='\u0e08\u0e33\u0e19\u0e27\u0e19\u0e40\u0e07\u0e34\u0e19\u0e17\u0e35\u0e48\u0e44\u0e21\u0e48\u0e44\u0e14\u0e49\u0e04\u0e37\u0e19 \/ Non-refund amount'><input aria-invalid='false' aria-required=\"true\"  aria-label='\u0e08\u0e33\u0e19\u0e27\u0e19\u0e40\u0e07\u0e34\u0e19\u0e17\u0e35\u0e48\u0e44\u0e21\u0e48\u0e44\u0e14\u0e49\u0e04\u0e37\u0e19 \/ Non-refund amount, Row 1' data-aria-label-template='\u0e08\u0e33\u0e19\u0e27\u0e19\u0e40\u0e07\u0e34\u0e19\u0e17\u0e35\u0e48\u0e44\u0e21\u0e48\u0e44\u0e14\u0e49\u0e04\u0e37\u0e19 \/ Non-refund amount, Row {0}' type='text' name='input_67[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_67_cell5 gform-grid-col' data-label='\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency'><input aria-invalid='false' aria-required=\"true\"  aria-label='\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency, Row 1' data-aria-label-template='\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency, Row {0}' type='text' name='input_67[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_1_68\"  class=\"gfield gfield--type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_68\"><label class='gfield_label gform-field-label' for='gform_browse_button_1_68' >\u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e22\u0e37\u0e19\u0e22\u0e31\u0e19\u0e01\u0e32\u0e23\u0e08\u0e48\u0e32\u0e22\u0e40\u0e07\u0e34\u0e19\u0e41\u0e25\u0e30\u0e01\u0e32\u0e23\u0e02\u0e2d\u0e04\u0e37\u0e19\u0e40\u0e07\u0e34\u0e19 \/ Confirmation of payment &amp; Confirmation of refund<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_1_68' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_1_68&quot;,&quot;container&quot;:&quot;gform_multifile_upload_1_68&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_1_68&quot;,&quot;filelist&quot;:&quot;gform_preview_1_68&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/?gf_page=1005716fe3bdff0&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,jpeg&quot;}],&quot;max_file_size&quot;:&quot;10485760b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:1,&quot;field_id&quot;:68},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_1_68&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_1_68' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_1_68' class='button gform_button_select_files' aria-describedby=\"gfield_upload_rules_1_68\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_68'>Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 10 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_1_68'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_1_68' class='ginput_preview_list'><\/div><\/div><div id=\"field_1_69\"  class=\"gfield gfield--type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_69\"><label class='gfield_label gform-field-label' for='gform_browse_button_1_69' >\u0e08\u0e14\u0e2b\u0e21\u0e32\u0e22\u0e08\u0e32\u0e01\u0e02\u0e19\u0e2a\u0e48\u0e07\u0e41\u0e08\u0e49\u0e07\u0e2a\u0e32\u0e40\u0e2b\u0e15\u0e38 \/ Letter from carrier detailing the reason<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_1_69' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_1_69&quot;,&quot;container&quot;:&quot;gform_multifile_upload_1_69&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_1_69&quot;,&quot;filelist&quot;:&quot;gform_preview_1_69&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/?gf_page=1005716fe3bdff0&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,jpeg&quot;}],&quot;max_file_size&quot;:&quot;10485760b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:1,&quot;field_id&quot;:69},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_1_69&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_1_69' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_1_69' class='button gform_button_select_files' aria-describedby=\"gfield_upload_rules_1_69\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_69'>Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 10 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_1_69'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_1_69' class='ginput_preview_list'><\/div><\/div><div id=\"field_1_70\"  class=\"gfield gfield--type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_70\"><label class='gfield_label gform-field-label' for='gform_browse_button_1_70' >\u0e43\u0e1a\u0e23\u0e31\u0e1a\u0e23\u0e2d\u0e07\u0e41\u0e1e\u0e17\u0e22\u0e4c \/ Physician&#039;s report describing significant symptoms<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_1_70' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_1_70&quot;,&quot;container&quot;:&quot;gform_multifile_upload_1_70&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_1_70&quot;,&quot;filelist&quot;:&quot;gform_preview_1_70&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/?gf_page=1005716fe3bdff0&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,jpeg&quot;}],&quot;max_file_size&quot;:&quot;10485760b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:1,&quot;field_id&quot;:70},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_1_70&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_1_70' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_1_70' class='button gform_button_select_files' aria-describedby=\"gfield_upload_rules_1_70\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_70'>Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 10 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_1_70'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_1_70' class='ginput_preview_list'><\/div><\/div><div id=\"field_1_71\"  class=\"gfield gfield--type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_71\"><label class='gfield_label gform-field-label' for='gform_browse_button_1_71' >\u0e43\u0e1a\u0e21\u0e23\u0e13\u0e1a\u0e31\u0e15\u0e23 \/ Death Certificate<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_1_71' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_1_71&quot;,&quot;container&quot;:&quot;gform_multifile_upload_1_71&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_1_71&quot;,&quot;filelist&quot;:&quot;gform_preview_1_71&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/?gf_page=1005716fe3bdff0&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,jpeg&quot;}],&quot;max_file_size&quot;:&quot;10485760b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:1,&quot;field_id&quot;:71},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_1_71&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_1_71' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_1_71' class='button gform_button_select_files' aria-describedby=\"gfield_upload_rules_1_71\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_71'>Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 10 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_1_71'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_1_71' class='ginput_preview_list'><\/div><\/div><div id=\"field_1_72\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_72\"><label class='gfield_label gform-field-label' for='input_1_72' >\u0e27\u0e31\u0e19\u0e17\u0e35\u0e48\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07\u0e16\u0e36\u0e07\u0e08\u0e23\u0e34\u0e07 \/ Actual arrival Date (Baggage Delay)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_72' id='input_1_72' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_72_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_72_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_72' class='gform_hidden' value='https:\/\/allianz-assistance.co.th\/travel\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_1_73\"  class=\"gfield gfield--type-time gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_73\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >\u0e40\u0e27\u0e25\u0e32\u0e17\u0e35\u0e48\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07\u0e16\u0e36\u0e07\u0e08\u0e23\u0e34\u0e07 \/ Actual arrival time (Baggage Delay)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class=\"ginput_container ginput_complex gform-grid-row\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_1_73'>\n                            <input type='text' maxlength='2' name='input_73[]' id='input_1_73_1' value=''    placeholder='HH' aria-required='true'   \/> \n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_1_73_1'>Hours<\/label>\n                        <\/div>\n                        <div class=\"below hour_minute_colon gform-grid-col\">:<\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='text' maxlength='2' name='input_73[]' id='input_1_73_2' value=''    placeholder='MM' aria-required='true'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_1_73_2'>Minutes<\/label>\n                        <\/div>\n                        \n                    <\/div><\/fieldset><div id=\"field_1_74\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_74\"><label class='gfield_label gform-field-label' for='input_1_74' >\u0e27\u0e31\u0e19\u0e17\u0e35\u0e48\u0e44\u0e14\u0e49\u0e23\u0e31\u0e1a\u0e2a\u0e31\u0e21\u0e20\u0e32\u0e23\u0e30 \/ Actual Receiving Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_74' id='input_1_74' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_74_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_74_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_74' class='gform_hidden' value='https:\/\/allianz-assistance.co.th\/travel\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_1_75\"  class=\"gfield gfield--type-time gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_75\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >\u0e40\u0e27\u0e25\u0e32\u0e17\u0e35\u0e48\u0e44\u0e14\u0e49\u0e23\u0e31\u0e1a\u0e2a\u0e31\u0e21\u0e20\u0e32\u0e23\u0e30 \/ Actual Receiving time<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class=\"ginput_container ginput_complex gform-grid-row\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_1_75'>\n                            <input type='text' maxlength='2' name='input_75[]' id='input_1_75_1' value=''    placeholder='HH' aria-required='true'   \/> \n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_1_75_1'>Hours<\/label>\n                        <\/div>\n                        <div class=\"below hour_minute_colon gform-grid-col\">:<\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='text' maxlength='2' name='input_75[]' id='input_1_75_2' value=''    placeholder='MM' aria-required='true'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_1_75_2'>Minutes<\/label>\n                        <\/div>\n                        \n                    <\/div><\/fieldset><div id=\"field_1_123\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_123\"><label class='gfield_label gform-field-label' for='input_1_123' >\u0e08\u0e38\u0e14\u0e2b\u0e21\u0e32\u0e22\u0e1b\u0e25\u0e32\u0e22\u0e17\u0e32\u0e07\u0e17\u0e35\u0e48\u0e15\u0e49\u0e2d\u0e07\u0e44\u0e14\u0e49\u0e23\u0e31\u0e1a\u0e01\u0e23\u0e30\u0e40\u0e1b\u0e4b\u0e32 \/ Arrival point that should receive the check in Baggage<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_123' id='input_1_123' type='text' value='' class='medium'  aria-describedby=\"gfield_description_1_123\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_1_123'>*\u0e44\u0e21\u0e48\u0e04\u0e38\u0e49\u0e21\u0e04\u0e23\u0e2d\u0e07\u0e2b\u0e32\u0e01\u0e1b\u0e25\u0e32\u0e22\u0e17\u0e32\u0e07\u0e40\u0e1b\u0e47\u0e19\u0e1b\u0e23\u0e30\u0e40\u0e17\u0e28\u0e44\u0e17\u0e22 \/ not cover if arrival point is Thailand<\/div><\/div><div id=\"field_1_76\"  class=\"gfield gfield--type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_76\"><label class='gfield_label gform-field-label' for='gform_browse_button_1_76' >\u0e1a\u0e2d\u0e23\u0e4c\u0e14\u0e14\u0e34\u0e49\u0e07\u0e1e\u0e32\u0e2a\u0e02\u0e2d\u0e07\u0e40\u0e17\u0e35\u0e48\u0e22\u0e27\u0e1a\u0e34\u0e19\u0e17\u0e35\u0e48\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07\u0e08\u0e23\u0e34\u0e07 \/ Boarding pass of actual flights (Baggage Delay)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_1_76' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_1_76&quot;,&quot;container&quot;:&quot;gform_multifile_upload_1_76&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_1_76&quot;,&quot;filelist&quot;:&quot;gform_preview_1_76&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/?gf_page=1005716fe3bdff0&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,jpeg&quot;}],&quot;max_file_size&quot;:&quot;10485760b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:1,&quot;field_id&quot;:76},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_1_76&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_1_76' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_1_76' class='button gform_button_select_files' aria-describedby=\"gfield_upload_rules_1_76\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_76'>Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 10 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_1_76'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_1_76' class='ginput_preview_list'><\/div><\/div><div id=\"field_1_77\"  class=\"gfield gfield--type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_77\"><label class='gfield_label gform-field-label' for='gform_browse_button_1_77' >\u0e08\u0e14\u0e2b\u0e21\u0e32\u0e22\u0e23\u0e30\u0e1a\u0e38\u0e27\u0e31\u0e19 \u0e41\u0e25\u0e30\u0e40\u0e27\u0e25\u0e32\u0e17\u0e35\u0e48\u0e23\u0e31\u0e1a\u0e2a\u0e31\u0e21\u0e20\u0e32\u0e23\u0e30\u0e08\u0e32\u0e01\u0e02\u0e19\u0e2a\u0e48\u0e07 \/ Report issued by Delivery Service stating date and time<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_1_77' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_1_77&quot;,&quot;container&quot;:&quot;gform_multifile_upload_1_77&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_1_77&quot;,&quot;filelist&quot;:&quot;gform_preview_1_77&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/?gf_page=1005716fe3bdff0&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,jpeg&quot;}],&quot;max_file_size&quot;:&quot;10485760b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:1,&quot;field_id&quot;:77},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_1_77&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_1_77' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_1_77' class='button gform_button_select_files' aria-describedby=\"gfield_upload_rules_1_77\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_77'>Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 10 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_1_77'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_1_77' class='ginput_preview_list'><\/div><\/div><div id=\"field_1_78\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_78\"><label class='gfield_label gform-field-label' for='input_1_78' >\u0e1b\u0e23\u0e30\u0e40\u0e20\u0e17\u0e02\u0e2d\u0e07\u0e40\u0e2b\u0e15\u0e38\u0e17\u0e35\u0e48\u0e40\u0e01\u0e34\u0e14 \/ Incident type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_78' id='input_1_78' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='\u0e01\u0e23\u0e38\u0e13\u0e32\u0e40\u0e25\u0e37\u0e2d\u0e01\u0e1b\u0e23\u0e30\u0e40\u0e20\u0e17\u0e02\u0e2d\u0e07\u0e40\u0e2b\u0e15\u0e38\u0e17\u0e35\u0e48\u0e40\u0e01\u0e34\u0e14' >\u0e01\u0e23\u0e38\u0e13\u0e32\u0e40\u0e25\u0e37\u0e2d\u0e01\u0e1b\u0e23\u0e30\u0e40\u0e20\u0e17\u0e02\u0e2d\u0e07\u0e40\u0e2b\u0e15\u0e38\u0e17\u0e35\u0e48\u0e40\u0e01\u0e34\u0e14<\/option><option value='\u0e2a\u0e31\u0e21\u0e20\u0e32\u0e23\u0e30\u0e2a\u0e39\u0e0d\u0e2b\u0e32\u0e22 \/ Baggage lost' >\u0e2a\u0e31\u0e21\u0e20\u0e32\u0e23\u0e30\u0e2a\u0e39\u0e0d\u0e2b\u0e32\u0e22 \/ Baggage lost<\/option><option value='\u0e40\u0e07\u0e34\u0e19\u0e1e\u0e01\u0e15\u0e34\u0e14\u0e15\u0e31\u0e27 \u0e2b\u0e23\u0e37\u0e2d\u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e2a\u0e33\u0e04\u0e31\u0e0d \u0e2a\u0e39\u0e0d\u0e2b\u0e32\u0e22 \/ Money or Personal document lost' >\u0e40\u0e07\u0e34\u0e19\u0e1e\u0e01\u0e15\u0e34\u0e14\u0e15\u0e31\u0e27 \u0e2b\u0e23\u0e37\u0e2d\u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e2a\u0e33\u0e04\u0e31\u0e0d \u0e2a\u0e39\u0e0d\u0e2b\u0e32\u0e22 \/ Money or Personal document lost<\/option><\/select><\/div><\/div><fieldset id=\"field_1_79\"  class=\"gfield gfield--type-list gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_79\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >\u0e23\u0e32\u0e22\u0e01\u0e32\u0e23\u0e2a\u0e34\u0e48\u0e07\u0e02\u0e2d\u0e07\u0e17\u0e35\u0e48\u0e2b\u0e32\u0e22 \/ List of item lost<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">\u0e0a\u0e37\u0e48\u0e2d\u0e23\u0e32\u0e22\u0e01\u0e32\u0e23 \/ Name of item<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">\u0e23\u0e32\u0e04\u0e32\u0e17\u0e35\u0e48\u0e0b\u0e37\u0e49\u0e2d \/ Purchasing Price<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">\u0e1b\u0e35\u0e17\u0e35\u0e48\u0e0b\u0e37\u0e49\u0e2d \/ Purchasing Year<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_79_cell1 gform-grid-col' data-label='\u0e0a\u0e37\u0e48\u0e2d\u0e23\u0e32\u0e22\u0e01\u0e32\u0e23 \/ Name of item'><input aria-invalid='false' aria-required=\"true\"  aria-label='\u0e0a\u0e37\u0e48\u0e2d\u0e23\u0e32\u0e22\u0e01\u0e32\u0e23 \/ Name of item, Row 1' data-aria-label-template='\u0e0a\u0e37\u0e48\u0e2d\u0e23\u0e32\u0e22\u0e01\u0e32\u0e23 \/ Name of item, Row {0}' type='text' name='input_79[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_79_cell2 gform-grid-col' data-label='\u0e23\u0e32\u0e04\u0e32\u0e17\u0e35\u0e48\u0e0b\u0e37\u0e49\u0e2d \/ Purchasing Price'><input aria-invalid='false' aria-required=\"true\"  aria-label='\u0e23\u0e32\u0e04\u0e32\u0e17\u0e35\u0e48\u0e0b\u0e37\u0e49\u0e2d \/ Purchasing Price, Row 1' data-aria-label-template='\u0e23\u0e32\u0e04\u0e32\u0e17\u0e35\u0e48\u0e0b\u0e37\u0e49\u0e2d \/ Purchasing Price, Row {0}' type='text' name='input_79[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_79_cell3 gform-grid-col' data-label='\u0e1b\u0e35\u0e17\u0e35\u0e48\u0e0b\u0e37\u0e49\u0e2d \/ Purchasing Year'><input aria-invalid='false' aria-required=\"true\"  aria-label='\u0e1b\u0e35\u0e17\u0e35\u0e48\u0e0b\u0e37\u0e49\u0e2d \/ Purchasing Year, Row 1' data-aria-label-template='\u0e1b\u0e35\u0e17\u0e35\u0e48\u0e0b\u0e37\u0e49\u0e2d \/ Purchasing Year, Row {0}' type='text' name='input_79[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_79_cell4 gform-grid-col' data-label='\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency'><input aria-invalid='false' aria-required=\"true\"  aria-label='\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency, Row 1' data-aria-label-template='\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency, Row {0}' type='text' name='input_79[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_1_80\"  class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_80\"><label class='gfield_label gform-field-label' for='input_1_80' >\u0e23\u0e32\u0e22\u0e25\u0e30\u0e40\u0e2d\u0e35\u0e22\u0e14\u0e02\u0e2d\u0e07\u0e40\u0e2b\u0e15\u0e38\u0e01\u0e32\u0e23 \/ Incident details<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_80' id='input_1_80' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_81\"  class=\"gfield gfield--type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_81\"><label class='gfield_label gform-field-label' for='gform_browse_button_1_81' >\u0e43\u0e1a\u0e41\u0e08\u0e49\u0e07\u0e04\u0e27\u0e32\u0e21 \u0e2b\u0e23\u0e37\u0e2d\u0e08\u0e14\u0e2b\u0e21\u0e32\u0e22\u0e08\u0e32\u0e01\u0e02\u0e19\u0e2a\u0e48\u0e07\u0e2a\u0e32\u0e18\u0e32\u0e23\u0e13\u0e30 \/ Police report or Letter from carrier (Loss of Baggage)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_1_81' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_1_81&quot;,&quot;container&quot;:&quot;gform_multifile_upload_1_81&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_1_81&quot;,&quot;filelist&quot;:&quot;gform_preview_1_81&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/?gf_page=1005716fe3bdff0&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,jpeg&quot;}],&quot;max_file_size&quot;:&quot;10485760b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:1,&quot;field_id&quot;:81},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_1_81&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_1_81' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_1_81' class='button gform_button_select_files' aria-describedby=\"gfield_upload_rules_1_81\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_81'>Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 10 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_1_81'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_1_81' class='ginput_preview_list'><\/div><\/div><fieldset id=\"field_1_126\"  class=\"gfield gfield--type-list gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_126\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >\u0e23\u0e32\u0e22\u0e01\u0e32\u0e23\u0e2a\u0e31\u0e21\u0e20\u0e32\u0e23\u0e30\u0e17\u0e35\u0e48\u0e40\u0e2a\u0e35\u0e22\u0e2b\u0e32\u0e22 \/ List of item baggage damage<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">\u0e0a\u0e37\u0e48\u0e2d\u0e23\u0e32\u0e22\u0e01\u0e32\u0e23\u0e2b\u0e23\u0e37\u0e2d\u0e41\u0e1a\u0e23\u0e19\u0e14\u0e4c  \/ Name of item or Brand<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">\u0e23\u0e32\u0e04\u0e32\u0e17\u0e35\u0e48\u0e0b\u0e37\u0e49\u0e2d \/ Purchasing Price<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">\u0e1b\u0e35\u0e17\u0e35\u0e48\u0e0b\u0e37\u0e49\u0e2d \/ Purchasing Year<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_126_cell1 gform-grid-col' data-label='\u0e0a\u0e37\u0e48\u0e2d\u0e23\u0e32\u0e22\u0e01\u0e32\u0e23\u0e2b\u0e23\u0e37\u0e2d\u0e41\u0e1a\u0e23\u0e19\u0e14\u0e4c  \/ Name of item or Brand'><input aria-invalid='false' aria-required=\"true\"  aria-label='\u0e0a\u0e37\u0e48\u0e2d\u0e23\u0e32\u0e22\u0e01\u0e32\u0e23\u0e2b\u0e23\u0e37\u0e2d\u0e41\u0e1a\u0e23\u0e19\u0e14\u0e4c  \/ Name of item or Brand, Row 1' data-aria-label-template='\u0e0a\u0e37\u0e48\u0e2d\u0e23\u0e32\u0e22\u0e01\u0e32\u0e23\u0e2b\u0e23\u0e37\u0e2d\u0e41\u0e1a\u0e23\u0e19\u0e14\u0e4c  \/ Name of item or Brand, Row {0}' type='text' name='input_126[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_126_cell2 gform-grid-col' data-label='\u0e23\u0e32\u0e04\u0e32\u0e17\u0e35\u0e48\u0e0b\u0e37\u0e49\u0e2d \/ Purchasing Price'><input aria-invalid='false' aria-required=\"true\"  aria-label='\u0e23\u0e32\u0e04\u0e32\u0e17\u0e35\u0e48\u0e0b\u0e37\u0e49\u0e2d \/ Purchasing Price, Row 1' data-aria-label-template='\u0e23\u0e32\u0e04\u0e32\u0e17\u0e35\u0e48\u0e0b\u0e37\u0e49\u0e2d \/ Purchasing Price, Row {0}' type='text' name='input_126[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_126_cell3 gform-grid-col' data-label='\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency'><input aria-invalid='false' aria-required=\"true\"  aria-label='\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency, Row 1' data-aria-label-template='\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency, Row {0}' type='text' name='input_126[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_126_cell4 gform-grid-col' data-label='\u0e1b\u0e35\u0e17\u0e35\u0e48\u0e0b\u0e37\u0e49\u0e2d \/ Purchasing Year'><input aria-invalid='false' aria-required=\"true\"  aria-label='\u0e1b\u0e35\u0e17\u0e35\u0e48\u0e0b\u0e37\u0e49\u0e2d \/ Purchasing Year, Row 1' data-aria-label-template='\u0e1b\u0e35\u0e17\u0e35\u0e48\u0e0b\u0e37\u0e49\u0e2d \/ Purchasing Year, Row {0}' type='text' name='input_126[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_1_127\"  class=\"gfield gfield--type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_127\"><label class='gfield_label gform-field-label' for='gform_browse_button_1_127' >PIR \u0e2b\u0e23\u0e37\u0e2d\u0e08\u0e14\u0e2b\u0e21\u0e32\u0e22\u0e23\u0e31\u0e1a\u0e23\u0e2d\u0e07\u0e04\u0e27\u0e32\u0e21\u0e40\u0e2a\u0e35\u0e22\u0e2b\u0e32\u0e22\u0e2d\u0e22\u0e48\u0e32\u0e07\u0e40\u0e1b\u0e47\u0e19\u0e17\u0e32\u0e07\u0e01\u0e32\u0e23\u0e08\u0e32\u0e01\u0e1c\u0e39\u0e49\u0e43\u0e2b\u0e49\u0e1a\u0e23\u0e34\u0e01\u0e32\u0e23 \/ PIR or official letter certifying the damage from provider<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_1_127' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_1_127&quot;,&quot;container&quot;:&quot;gform_multifile_upload_1_127&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_1_127&quot;,&quot;filelist&quot;:&quot;gform_preview_1_127&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/?gf_page=1005716fe3bdff0&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,jpeg&quot;}],&quot;max_file_size&quot;:&quot;10485760b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:1,&quot;field_id&quot;:127},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_1_127&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_1_127' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_1_127' class='button gform_button_select_files' aria-describedby=\"gfield_upload_rules_1_127\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_127'>Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 10 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_1_127'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_1_127' class='ginput_preview_list'><\/div><\/div><div id=\"field_1_128\"  class=\"gfield gfield--type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_128\"><label class='gfield_label gform-field-label' for='gform_browse_button_1_128' >\u0e23\u0e39\u0e1b\u0e20\u0e32\u0e1e\u0e17\u0e35\u0e48\u0e41\u0e2a\u0e14\u0e07\u0e04\u0e27\u0e32\u0e21\u0e40\u0e2a\u0e35\u0e22\u0e2b\u0e32\u0e22\u0e17\u0e35\u0e48\u0e40\u0e01\u0e34\u0e14\u0e02\u0e36\u0e49\u0e19 \/ Pictures showing the extent of damage<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_1_128' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_1_128&quot;,&quot;container&quot;:&quot;gform_multifile_upload_1_128&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_1_128&quot;,&quot;filelist&quot;:&quot;gform_preview_1_128&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/?gf_page=1005716fe3bdff0&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,jpeg&quot;}],&quot;max_file_size&quot;:&quot;10485760b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:1,&quot;field_id&quot;:128},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_1_128&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_1_128' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_1_128' class='button gform_button_select_files' aria-describedby=\"gfield_upload_rules_1_128\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_128'>Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 10 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_1_128'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_1_128' class='ginput_preview_list'><\/div><\/div><div id=\"field_1_129\"  class=\"gfield gfield--type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_129\"><label class='gfield_label gform-field-label' for='gform_browse_button_1_129' >\u0e43\u0e1a\u0e40\u0e2a\u0e19\u0e2d\u0e23\u0e32\u0e04\u0e32\u0e04\u0e48\u0e32\u0e0b\u0e48\u0e2d\u0e21\u0e2b\u0e23\u0e37\u0e2d\u0e43\u0e1a\u0e40\u0e2a\u0e23\u0e47\u0e08\u0e04\u0e48\u0e32\u0e0b\u0e48\u0e2d\u0e21 (\u0e16\u0e49\u0e32\u0e21\u0e35) \/ Repair quote or receipt, if any<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_1_129' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_1_129&quot;,&quot;container&quot;:&quot;gform_multifile_upload_1_129&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_1_129&quot;,&quot;filelist&quot;:&quot;gform_preview_1_129&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/?gf_page=1005716fe3bdff0&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,jpeg&quot;}],&quot;max_file_size&quot;:&quot;10485760b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:1,&quot;field_id&quot;:129},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_1_129&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_1_129' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_1_129' class='button gform_button_select_files' aria-describedby=\"gfield_upload_rules_1_129\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_129'>Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 10 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_1_129'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_1_129' class='ginput_preview_list'><\/div><\/div><div id=\"field_1_82\"  class=\"gfield gfield--type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_82\"><label class='gfield_label gform-field-label' for='gform_browse_button_1_82' >\u0e2b\u0e25\u0e31\u0e01\u0e10\u0e32\u0e19\u0e41\u0e2a\u0e14\u0e07\u0e04\u0e27\u0e32\u0e21\u0e40\u0e1b\u0e47\u0e19\u0e40\u0e08\u0e49\u0e32\u0e02\u0e2d\u0e07 \/ Proof of ownership for the item lost<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_1_82' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_1_82&quot;,&quot;container&quot;:&quot;gform_multifile_upload_1_82&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_1_82&quot;,&quot;filelist&quot;:&quot;gform_preview_1_82&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/?gf_page=1005716fe3bdff0&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,jpeg&quot;}],&quot;max_file_size&quot;:&quot;10485760b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:1,&quot;field_id&quot;:82},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_1_82&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_1_82' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_1_82' class='button gform_button_select_files' aria-describedby=\"gfield_upload_rules_1_82\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_82'>Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 10 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_1_82'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_1_82' class='ginput_preview_list'><\/div><\/div><fieldset id=\"field_1_83\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_83\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >\u0e2a\u0e34\u0e48\u0e07\u0e02\u0e2d\u0e07\u0e17\u0e35\u0e48\u0e2b\u0e32\u0e22 \/ List of item lost<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_83'><div class='gchoice gchoice_1_83_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_83.1' type='checkbox'  value='\u0e40\u0e07\u0e34\u0e19\u0e1e\u0e01\u0e15\u0e34\u0e14\u0e15\u0e31\u0e27 \/ Money'  id='choice_1_83_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_83_1' id='label_1_83_1' class='gform-field-label gform-field-label--type-inline'>\u0e40\u0e07\u0e34\u0e19\u0e1e\u0e01\u0e15\u0e34\u0e14\u0e15\u0e31\u0e27 \/ Money<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_83_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_83.2' type='checkbox'  value='\u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e2a\u0e48\u0e27\u0e19\u0e15\u0e31\u0e27 \/ Personal Document'  id='choice_1_83_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_83_2' id='label_1_83_2' class='gform-field-label gform-field-label--type-inline'>\u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e2a\u0e48\u0e27\u0e19\u0e15\u0e31\u0e27 \/ Personal Document<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_83_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_83.3' type='checkbox'  value='\u0e2d\u0e37\u0e48\u0e19\u0e46 \/ Other'  id='choice_1_83_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_83_3' id='label_1_83_3' class='gform-field-label gform-field-label--type-inline'>\u0e2d\u0e37\u0e48\u0e19\u0e46 \/ Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_84\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_84\"><label class='gfield_label gform-field-label' for='input_1_84' >\u0e42\u0e1b\u0e23\u0e14\u0e23\u0e30\u0e1a\u0e38 \/ Please Specific<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_84' id='input_1_84' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_85\"  class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_85\"><label class='gfield_label gform-field-label' for='input_1_85' >\u0e23\u0e32\u0e22\u0e25\u0e30\u0e40\u0e2d\u0e35\u0e22\u0e14\u0e02\u0e2d\u0e07\u0e40\u0e2b\u0e15\u0e38\u0e01\u0e32\u0e23 \/ Incident details<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_85' id='input_1_85' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_86\"  class=\"gfield gfield--type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_86\"><label class='gfield_label gform-field-label' for='gform_browse_button_1_86' >\u0e43\u0e1a\u0e41\u0e08\u0e49\u0e07\u0e04\u0e27\u0e32\u0e21 \u0e2b\u0e23\u0e37\u0e2d\u0e08\u0e14\u0e2b\u0e21\u0e32\u0e22\u0e08\u0e32\u0e01\u0e02\u0e19\u0e2a\u0e48\u0e07\u0e2a\u0e32\u0e18\u0e32\u0e23\u0e13\u0e30 \/ Police report or Letter from carrier<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_1_86' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_1_86&quot;,&quot;container&quot;:&quot;gform_multifile_upload_1_86&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_1_86&quot;,&quot;filelist&quot;:&quot;gform_preview_1_86&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/?gf_page=1005716fe3bdff0&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,jpeg&quot;}],&quot;max_file_size&quot;:&quot;10485760b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:1,&quot;field_id&quot;:86},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_1_86&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_1_86' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_1_86' class='button gform_button_select_files' aria-describedby=\"gfield_upload_rules_1_86\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_86'>Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 10 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_1_86'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_1_86' class='ginput_preview_list'><\/div><\/div><div id=\"field_1_87\"  class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_87\"><label class='gfield_label gform-field-label' for='input_1_87' >\u0e22\u0e2d\u0e14\u0e2a\u0e34\u0e19\u0e44\u0e2b\u0e21\u0e17\u0e35\u0e48\u0e15\u0e49\u0e2d\u0e07\u0e01\u0e32\u0e23\u0e40\u0e23\u0e35\u0e22\u0e01\u0e23\u0e49\u0e2d\u0e07 \/ Claim Expense<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_87' id='input_1_87' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_88\"  class=\"gfield gfield--type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_88\"><label class='gfield_label gform-field-label' for='input_1_88' >\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_88' id='input_1_88' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='\u0e01\u0e23\u0e38\u0e13\u0e32\u0e40\u0e25\u0e37\u0e2d\u0e01\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19' >\u0e01\u0e23\u0e38\u0e13\u0e32\u0e40\u0e25\u0e37\u0e2d\u0e01\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19<\/option><option value='AED' >AED<\/option><option value='AFN' >AFN<\/option><option value='ALL' >ALL<\/option><option value='AMD' >AMD<\/option><option value='ANG' >ANG<\/option><option value='AOA' >AOA<\/option><option value='ARS' >ARS<\/option><option value='AUD' >AUD<\/option><option value='AWG' >AWG<\/option><option value='AZN' >AZN<\/option><option value='BAM' >BAM<\/option><option value='BBD' >BBD<\/option><option value='BDT' >BDT<\/option><option value='BGN' >BGN<\/option><option value='BHD' >BHD<\/option><option value='BIF' >BIF<\/option><option value='BMD' >BMD<\/option><option value='BND' >BND<\/option><option value='BOB' >BOB<\/option><option value='BRL' >BRL<\/option><option value='BSD' >BSD<\/option><option value='BTN' >BTN<\/option><option value='BWP' >BWP<\/option><option value='BYN' >BYN<\/option><option value='BZD' >BZD<\/option><option value='CAD' >CAD<\/option><option value='CDF' >CDF<\/option><option value='CHF' >CHF<\/option><option value='CLP' >CLP<\/option><option value='CNY' >CNY<\/option><option value='COP' >COP<\/option><option value='CRC' >CRC<\/option><option value='CUP' >CUP<\/option><option value='CVE' >CVE<\/option><option value='CZK' >CZK<\/option><option value='DJF' >DJF<\/option><option value='DKK' >DKK<\/option><option value='DOP' >DOP<\/option><option value='DZD' >DZD<\/option><option value='EGP' >EGP<\/option><option value='ERN' >ERN<\/option><option value='ETB' >ETB<\/option><option value='EUR' >EUR<\/option><option value='FJD' >FJD<\/option><option value='FKP' >FKP<\/option><option value='GBP' >GBP<\/option><option value='GEL' >GEL<\/option><option value='GGP' >GGP<\/option><option value='GHS' >GHS<\/option><option value='GIP' >GIP<\/option><option value='GMD' >GMD<\/option><option value='GNF' >GNF<\/option><option value='GTQ' >GTQ<\/option><option value='GYD' >GYD<\/option><option value='HKD' >HKD<\/option><option value='HNL' >HNL<\/option><option value='HRK' >HRK<\/option><option value='HTG' >HTG<\/option><option value='HUF' >HUF<\/option><option value='IDR' >IDR<\/option><option value='ILS' >ILS<\/option><option value='IMP' >IMP<\/option><option value='INR' >INR<\/option><option value='IQD' >IQD<\/option><option value='IRR' >IRR<\/option><option value='ISK' >ISK<\/option><option value='JEP' >JEP<\/option><option value='JMD' >JMD<\/option><option value='JOD' >JOD<\/option><option value='JPY' >JPY<\/option><option value='KES' >KES<\/option><option value='KGS' >KGS<\/option><option value='KHR' >KHR<\/option><option value='KMF' >KMF<\/option><option value='KPW' >KPW<\/option><option value='KRW' >KRW<\/option><option value='KWD' >KWD<\/option><option value='KYD' >KYD<\/option><option value='KZT' >KZT<\/option><option value='LAK' >LAK<\/option><option value='LBP' >LBP<\/option><option value='LKR' >LKR<\/option><option value='LRD' >LRD<\/option><option value='LSL' >LSL<\/option><option value='LYD' >LYD<\/option><option value='MAD' >MAD<\/option><option value='MDL' >MDL<\/option><option value='MGA' >MGA<\/option><option value='MKD' >MKD<\/option><option value='MMK' >MMK<\/option><option value='MNT' >MNT<\/option><option value='MOP' >MOP<\/option><option value='MRU' >MRU<\/option><option value='MUR' >MUR<\/option><option value='MVR' >MVR<\/option><option value='MWK' >MWK<\/option><option value='MXN' >MXN<\/option><option value='MYR' >MYR<\/option><option value='MZN' >MZN<\/option><option value='NAD' >NAD<\/option><option value='NGN' >NGN<\/option><option value='NIO' >NIO<\/option><option value='NOK' >NOK<\/option><option value='NPR' >NPR<\/option><option value='NZD' >NZD<\/option><option value='OMR' >OMR<\/option><option value='PEN' >PEN<\/option><option value='PGK' >PGK<\/option><option value='PHP' >PHP<\/option><option value='PKR' >PKR<\/option><option value='PLN' >PLN<\/option><option value='PYG' >PYG<\/option><option value='QAR' >QAR<\/option><option value='RON' >RON<\/option><option value='RSD' >RSD<\/option><option value='RUB' >RUB<\/option><option value='RWF' >RWF<\/option><option value='SAR' >SAR<\/option><option value='SBD' >SBD<\/option><option value='SCR' >SCR<\/option><option value='SDG' >SDG<\/option><option value='SEK' >SEK<\/option><option value='SGD' >SGD<\/option><option value='SHP' >SHP<\/option><option value='SLL' >SLL<\/option><option value='SOS' >SOS<\/option><option value='SRD' >SRD<\/option><option value='SSP' >SSP<\/option><option value='STN' >STN<\/option><option value='SYP' >SYP<\/option><option value='SZL' >SZL<\/option><option value='THB' >THB<\/option><option value='TJS' >TJS<\/option><option value='TMT' >TMT<\/option><option value='TND' >TND<\/option><option value='TOP' >TOP<\/option><option value='TRY' >TRY<\/option><option value='TTD' >TTD<\/option><option value='TWD' >TWD<\/option><option value='TZS' >TZS<\/option><option value='UAH' >UAH<\/option><option value='UGX' >UGX<\/option><option value='USD' >USD<\/option><option value='UYU' >UYU<\/option><option value='UZS' >UZS<\/option><option value='VES' >VES<\/option><option value='VND' >VND<\/option><option value='VUV' >VUV<\/option><option value='WST' >WST<\/option><option value='XAF' >XAF<\/option><option value='XCD' >XCD<\/option><option value='XDR' >XDR<\/option><option value='XOF' >XOF<\/option><option value='XPF' >XPF<\/option><option value='YER' >YER<\/option><option value='ZAR' >ZAR<\/option><option value='ZMW' >ZMW<\/option><\/select><\/div><\/div><div id=\"field_1_89\"  class=\"gfield gfield--type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_89\"><label class='gfield_label gform-field-label' for='gform_browse_button_1_89' >\u0e2a\u0e31\u0e0d\u0e0d\u0e32\u0e01\u0e32\u0e23\u0e40\u0e0a\u0e48\u0e32 \/ Rental Agreement<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_1_89' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_1_89&quot;,&quot;container&quot;:&quot;gform_multifile_upload_1_89&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_1_89&quot;,&quot;filelist&quot;:&quot;gform_preview_1_89&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/?gf_page=1005716fe3bdff0&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,jpeg&quot;}],&quot;max_file_size&quot;:&quot;10485760b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:1,&quot;field_id&quot;:89},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_1_89&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_1_89' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_1_89' class='button gform_button_select_files' aria-describedby=\"gfield_upload_rules_1_89\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_89'>Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 10 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_1_89'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_1_89' class='ginput_preview_list'><\/div><\/div><div id=\"field_1_90\"  class=\"gfield gfield--type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_90\"><label class='gfield_label gform-field-label' for='gform_browse_button_1_90' >\u0e08\u0e14\u0e2b\u0e21\u0e32\u0e22\u0e41\u0e08\u0e49\u0e07\u0e01\u0e32\u0e23\u0e40\u0e2a\u0e35\u0e22\u0e2b\u0e32\u0e22 \/ Damage report<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_1_90' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_1_90&quot;,&quot;container&quot;:&quot;gform_multifile_upload_1_90&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_1_90&quot;,&quot;filelist&quot;:&quot;gform_preview_1_90&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/?gf_page=1005716fe3bdff0&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,jpeg&quot;}],&quot;max_file_size&quot;:&quot;10485760b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:1,&quot;field_id&quot;:90},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_1_90&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_1_90' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_1_90' class='button gform_button_select_files' aria-describedby=\"gfield_upload_rules_1_90\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_90'>Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 10 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_1_90'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_1_90' class='ginput_preview_list'><\/div><\/div><div id=\"field_1_91\"  class=\"gfield gfield--type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_91\"><label class='gfield_label gform-field-label' for='gform_browse_button_1_91' >\u0e43\u0e1a\u0e40\u0e2a\u0e23\u0e47\u0e08\u0e04\u0e48\u0e32\u0e40\u0e2a\u0e35\u0e22\u0e2b\u0e32\u0e22\u0e2a\u0e48\u0e27\u0e19\u0e41\u0e23\u0e01 \/ Invoicing or Receipts of excess amount<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_1_91' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_1_91&quot;,&quot;container&quot;:&quot;gform_multifile_upload_1_91&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_1_91&quot;,&quot;filelist&quot;:&quot;gform_preview_1_91&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/?gf_page=1005716fe3bdff0&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,jpeg&quot;}],&quot;max_file_size&quot;:&quot;10485760b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:1,&quot;field_id&quot;:91},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_1_91&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_1_91' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_1_91' class='button gform_button_select_files' aria-describedby=\"gfield_upload_rules_1_91\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_91'>Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 10 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_1_91'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_1_91' class='ginput_preview_list'><\/div><\/div><div id=\"field_1_118\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_118\"><label class='gfield_label gform-field-label' for='input_1_118' >\u0e01\u0e23\u0e38\u0e13\u0e32\u0e23\u0e30\u0e1a\u0e38\u0e04\u0e27\u0e32\u0e21\u0e04\u0e38\u0e49\u0e21\u0e04\u0e23\u0e2d\u0e07 \u0e15\u0e32\u0e21\u0e2b\u0e19\u0e49\u0e32\u0e15\u0e32\u0e23\u0e32\u0e07\u0e17\u0e35\u0e48\u0e15\u0e49\u0e2d\u0e07\u0e01\u0e32\u0e23\u0e40\u0e23\u0e35\u0e22\u0e01\u0e23\u0e49\u0e2d\u0e07\u0e2a\u0e34\u0e19\u0e44\u0e2b\u0e21 \/ Please indicate which benefits you are claiming<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_118' id='input_1_118' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_119\"  class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_119\"><label class='gfield_label gform-field-label' for='input_1_119' >\u0e01\u0e23\u0e38\u0e13\u0e32\u0e2d\u0e18\u0e34\u0e1a\u0e32\u0e22\u0e40\u0e2b\u0e15\u0e38\u0e01\u0e32\u0e23\u0e13\u0e4c\u0e17\u0e35\u0e48\u0e15\u0e49\u0e2d\u0e07\u0e01\u0e32\u0e23\u0e40\u0e23\u0e35\u0e22\u0e01\u0e23\u0e49\u0e2d\u0e07\u0e42\u0e14\u0e22\u0e25\u0e30\u0e40\u0e2d\u0e35\u0e22\u0e14 (\u0e40\u0e2b\u0e15\u0e38\u0e01\u0e32\u0e23\u0e13\u0e4c \u0e2a\u0e16\u0e32\u0e19\u0e17\u0e35\u0e48\u0e40\u0e01\u0e34\u0e14\u0e40\u0e2b\u0e15\u0e38 \u0e40\u0e27\u0e25\u0e32 \u0e41\u0e25\u0e30\u0e2d\u0e37\u0e48\u0e19\u0e46) \/ Please describe your incident in details (type of incident, location, time and etc.)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_119' id='input_1_119' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_121\"  class=\"gfield gfield--type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_121\"><label class='gfield_label gform-field-label' for='gform_browse_button_1_121' >\u0e01\u0e23\u0e38\u0e13\u0e32\u0e41\u0e19\u0e1a\u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e2d\u0e37\u0e48\u0e19\u0e17\u0e35\u0e48\u0e40\u0e01\u0e35\u0e48\u0e22\u0e27\u0e02\u0e49\u0e2d\u0e07 \/ Please attach the related documents<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_1_121' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_1_121&quot;,&quot;container&quot;:&quot;gform_multifile_upload_1_121&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_1_121&quot;,&quot;filelist&quot;:&quot;gform_preview_1_121&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/?gf_page=1005716fe3bdff0&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,jpeg&quot;}],&quot;max_file_size&quot;:&quot;10485760b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:1,&quot;field_id&quot;:121},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_1_121&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_1_121' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_1_121' class='button gform_button_select_files' aria-describedby=\"gfield_upload_rules_1_121\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_121'>Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 10 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_1_121'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_1_121' class='ginput_preview_list'><\/div><\/div><div id=\"field_1_124\"  class=\"gfield gfield--type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_124\"><label class='gfield_label gform-field-label' for='gform_browse_button_1_124' >\u0e01\u0e23\u0e38\u0e13\u0e32\u0e41\u0e19\u0e1a\u0e40\u0e2d\u0e01\u0e2a\u0e32\u0e23\u0e2d\u0e37\u0e48\u0e19\u0e17\u0e35\u0e48\u0e40\u0e01\u0e35\u0e48\u0e22\u0e27\u0e02\u0e49\u0e2d\u0e07 \/ Please attach the related documents<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_1_124' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_1_124&quot;,&quot;container&quot;:&quot;gform_multifile_upload_1_124&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_1_124&quot;,&quot;filelist&quot;:&quot;gform_preview_1_124&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/?gf_page=1005716fe3bdff0&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,jpeg&quot;}],&quot;max_file_size&quot;:&quot;10485760b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:1,&quot;field_id&quot;:124},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_1_124&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_1_124' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_1_124' class='button gform_button_select_files' aria-describedby=\"gfield_upload_rules_1_124\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_124'>Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 10 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_1_124'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_1_124' class='ginput_preview_list'><\/div><\/div><fieldset id=\"field_1_120\"  class=\"gfield gfield--type-list gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_120\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >\u0e23\u0e32\u0e22\u0e01\u0e32\u0e23\u0e04\u0e48\u0e32\u0e43\u0e0a\u0e49\u0e08\u0e48\u0e32\u0e22 \/ Expenses List<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">\u0e23\u0e32\u0e22\u0e01\u0e32\u0e23\u0e04\u0e48\u0e32\u0e43\u0e0a\u0e49\u0e08\u0e48\u0e32\u0e22 \/ Expenses list<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">\u0e08\u0e33\u0e19\u0e27\u0e19 \/ Amount<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_120_cell1 gform-grid-col' data-label='\u0e23\u0e32\u0e22\u0e01\u0e32\u0e23\u0e04\u0e48\u0e32\u0e43\u0e0a\u0e49\u0e08\u0e48\u0e32\u0e22 \/ Expenses list'><input aria-invalid='false' aria-required=\"true\"  aria-label='\u0e23\u0e32\u0e22\u0e01\u0e32\u0e23\u0e04\u0e48\u0e32\u0e43\u0e0a\u0e49\u0e08\u0e48\u0e32\u0e22 \/ Expenses list, Row 1' data-aria-label-template='\u0e23\u0e32\u0e22\u0e01\u0e32\u0e23\u0e04\u0e48\u0e32\u0e43\u0e0a\u0e49\u0e08\u0e48\u0e32\u0e22 \/ Expenses list, Row {0}' type='text' name='input_120[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_120_cell2 gform-grid-col' data-label='\u0e08\u0e33\u0e19\u0e27\u0e19 \/ Amount'><input aria-invalid='false' aria-required=\"true\"  aria-label='\u0e08\u0e33\u0e19\u0e27\u0e19 \/ Amount, Row 1' data-aria-label-template='\u0e08\u0e33\u0e19\u0e27\u0e19 \/ Amount, Row {0}' type='text' name='input_120[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_120_cell3 gform-grid-col' data-label='\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency'><input aria-invalid='false' aria-required=\"true\"  aria-label='\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency, Row 1' data-aria-label-template='\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency, Row {0}' type='text' name='input_120[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_1_131\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_131\"><label class='gfield_label gform-field-label' for='input_1_131' >\u0e17\u0e48\u0e32\u0e19\u0e44\u0e14\u0e49\u0e23\u0e31\u0e1a\u0e01\u0e32\u0e23\u0e0a\u0e14\u0e40\u0e0a\u0e22\u0e08\u0e32\u0e01\u0e2a\u0e32\u0e22\u0e01\u0e32\u0e23\u0e1a\u0e34\u0e19 \u0e2a\u0e19\u0e32\u0e21\u0e1a\u0e34\u0e19 \u0e1c\u0e39\u0e49\u0e43\u0e2b\u0e49\u0e1a\u0e23\u0e34\u0e01\u0e32\u0e23 \u0e2b\u0e23\u0e37\u0e2d\u0e1b\u0e23\u0e30\u0e01\u0e31\u0e19\u0e2d\u0e37\u0e48\u0e19 \u0e19\u0e2d\u0e01\u0e08\u0e32\u0e01\u0e1b\u0e23\u0e30\u0e01\u0e31\u0e19\u0e01\u0e32\u0e23\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07\u0e09\u0e1a\u0e31\u0e1a\u0e19\u0e35\u0e49\u0e2b\u0e23\u0e37\u0e2d\u0e44\u0e21\u0e48 \/ Do you receive any form of compensation from any airline, airport, service provider, or insurance company other than this policy?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_131' id='input_1_131' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='\u0e01\u0e23\u0e38\u0e13\u0e32\u0e40\u0e25\u0e37\u0e2d\u0e01\u0e23\u0e39\u0e1b\u0e41\u0e1a\u0e1a\u0e01\u0e32\u0e23\u0e0a\u0e14\u0e40\u0e0a\u0e22\u0e17\u0e35\u0e48\u0e44\u0e14\u0e49\u0e23\u0e31\u0e1a\u0e2b\u0e23\u0e37\u0e2d\u0e01\u0e33\u0e25\u0e31\u0e07\u0e17\u0e35\u0e48\u0e08\u0e30\u0e44\u0e14\u0e49\u0e23\u0e31\u0e1a\u0e08\u0e32\u0e01\u0e41\u0e2b\u0e25\u0e48\u0e07\u0e2d\u0e37\u0e48\u0e19' >\u0e01\u0e23\u0e38\u0e13\u0e32\u0e40\u0e25\u0e37\u0e2d\u0e01\u0e23\u0e39\u0e1b\u0e41\u0e1a\u0e1a\u0e01\u0e32\u0e23\u0e0a\u0e14\u0e40\u0e0a\u0e22\u0e17\u0e35\u0e48\u0e44\u0e14\u0e49\u0e23\u0e31\u0e1a\u0e2b\u0e23\u0e37\u0e2d\u0e01\u0e33\u0e25\u0e31\u0e07\u0e17\u0e35\u0e48\u0e08\u0e30\u0e44\u0e14\u0e49\u0e23\u0e31\u0e1a\u0e08\u0e32\u0e01\u0e41\u0e2b\u0e25\u0e48\u0e07\u0e2d\u0e37\u0e48\u0e19<\/option><option value='\u0e04\u0e27\u0e32\u0e21\u0e04\u0e38\u0e49\u0e21\u0e04\u0e23\u0e2d\u0e07\u0e08\u0e32\u0e01\u0e1b\u0e23\u0e30\u0e01\u0e31\u0e19 \u0e2b\u0e23\u0e37\u0e2d\u0e2a\u0e27\u0e31\u0e2a\u0e14\u0e34\u0e01\u0e32\u0e23\u0e2d\u0e37\u0e48\u0e19 \/ Coverage from other insurance\/benefit' >\u0e04\u0e27\u0e32\u0e21\u0e04\u0e38\u0e49\u0e21\u0e04\u0e23\u0e2d\u0e07\u0e08\u0e32\u0e01\u0e1b\u0e23\u0e30\u0e01\u0e31\u0e19 \u0e2b\u0e23\u0e37\u0e2d\u0e2a\u0e27\u0e31\u0e2a\u0e14\u0e34\u0e01\u0e32\u0e23\u0e2d\u0e37\u0e48\u0e19 \/ Coverage from other insurance\/benefit<\/option><option value='\u0e40\u0e07\u0e34\u0e19\u0e2a\u0e14 \u0e40\u0e07\u0e34\u0e19\u0e42\u0e2d\u0e19\u0e40\u0e02\u0e49\u0e32\u0e1a\u0e31\u0e0d\u0e0a\u0e35 \u0e01\u0e32\u0e23\u0e04\u0e37\u0e19\u0e40\u0e07\u0e34\u0e19 \u0e08\u0e32\u0e01\u0e1c\u0e39\u0e49\u0e43\u0e2b\u0e49\u0e1a\u0e23\u0e34\u0e01\u0e32\u0e23 \/ Cash, bank transfer or refund from provider' >\u0e40\u0e07\u0e34\u0e19\u0e2a\u0e14 \u0e40\u0e07\u0e34\u0e19\u0e42\u0e2d\u0e19\u0e40\u0e02\u0e49\u0e32\u0e1a\u0e31\u0e0d\u0e0a\u0e35 \u0e01\u0e32\u0e23\u0e04\u0e37\u0e19\u0e40\u0e07\u0e34\u0e19 \u0e08\u0e32\u0e01\u0e1c\u0e39\u0e49\u0e43\u0e2b\u0e49\u0e1a\u0e23\u0e34\u0e01\u0e32\u0e23 \/ Cash, bank transfer or refund from provider<\/option><option value='\u0e23\u0e2d\u0e01\u0e32\u0e23\u0e22\u0e37\u0e19\u0e22\u0e31\u0e19\u0e04\u0e37\u0e19\u0e40\u0e07\u0e34\u0e19 \u0e04\u0e27\u0e32\u0e21\u0e04\u0e38\u0e49\u0e21\u0e04\u0e23\u0e2d\u0e07\u0e08\u0e32\u0e01\u0e41\u0e2b\u0e25\u0e48\u0e07\u0e2d\u0e37\u0e48\u0e19\u0e2a\u0e27\u0e31\u0e2a\u0e14\u0e34\u0e01\u0e32\u0e23\u0e2d\u0e37\u0e48\u0e19 \u0e2b\u0e23\u0e37\u0e2d\u0e1c\u0e39\u0e49\u0e43\u0e2b\u0e49\u0e1a\u0e23\u0e34\u0e01\u0e32\u0e23 \/ Awaiting refund\/decision from any other source' >\u0e23\u0e2d\u0e01\u0e32\u0e23\u0e22\u0e37\u0e19\u0e22\u0e31\u0e19\u0e04\u0e37\u0e19\u0e40\u0e07\u0e34\u0e19 \u0e04\u0e27\u0e32\u0e21\u0e04\u0e38\u0e49\u0e21\u0e04\u0e23\u0e2d\u0e07\u0e08\u0e32\u0e01\u0e41\u0e2b\u0e25\u0e48\u0e07\u0e2d\u0e37\u0e48\u0e19\u0e2a\u0e27\u0e31\u0e2a\u0e14\u0e34\u0e01\u0e32\u0e23\u0e2d\u0e37\u0e48\u0e19 \u0e2b\u0e23\u0e37\u0e2d\u0e1c\u0e39\u0e49\u0e43\u0e2b\u0e49\u0e1a\u0e23\u0e34\u0e01\u0e32\u0e23 \/ Awaiting refund\/decision from any other source<\/option><option value='\u0e2d\u0e37\u0e48\u0e19\u0e46 \u0e42\u0e1b\u0e23\u0e14\u0e23\u0e30\u0e1a\u0e38 \/ Other, please specify' >\u0e2d\u0e37\u0e48\u0e19\u0e46 \u0e42\u0e1b\u0e23\u0e14\u0e23\u0e30\u0e1a\u0e38 \/ Other, please specify<\/option><option value='\u0e44\u0e21\u0e48\u0e44\u0e14\u0e49\u0e23\u0e31\u0e1a\u0e01\u0e32\u0e23\u0e0a\u0e14\u0e40\u0e0a\u0e22\u0e43\u0e14\u0e46 \/ No compensation' >\u0e44\u0e21\u0e48\u0e44\u0e14\u0e49\u0e23\u0e31\u0e1a\u0e01\u0e32\u0e23\u0e0a\u0e14\u0e40\u0e0a\u0e22\u0e43\u0e14\u0e46 \/ No compensation<\/option><\/select><\/div><\/div><div id=\"field_1_136\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_136\"><label class='gfield_label gform-field-label' for='input_1_136' >\u0e17\u0e48\u0e32\u0e19\u0e44\u0e14\u0e49\u0e23\u0e31\u0e1a\u0e01\u0e32\u0e23\u0e0a\u0e14\u0e40\u0e0a\u0e22\u0e08\u0e32\u0e01\u0e2a\u0e32\u0e22\u0e01\u0e32\u0e23\u0e1a\u0e34\u0e19 \u0e2a\u0e19\u0e32\u0e21\u0e1a\u0e34\u0e19 \u0e1c\u0e39\u0e49\u0e43\u0e2b\u0e49\u0e1a\u0e23\u0e34\u0e01\u0e32\u0e23 \u0e2b\u0e23\u0e37\u0e2d\u0e1b\u0e23\u0e30\u0e01\u0e31\u0e19\u0e2d\u0e37\u0e48\u0e19 \u0e19\u0e2d\u0e01\u0e08\u0e32\u0e01\u0e1b\u0e23\u0e30\u0e01\u0e31\u0e19\u0e01\u0e32\u0e23\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07\u0e09\u0e1a\u0e31\u0e1a\u0e19\u0e35\u0e49\u0e2b\u0e23\u0e37\u0e2d\u0e44\u0e21\u0e48 \/ Do you receive any form of compensation from any airline, airport, service provider, or insurance company other than this policy?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_136' id='input_1_136' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='\u0e01\u0e23\u0e38\u0e13\u0e32\u0e40\u0e25\u0e37\u0e2d\u0e01\u0e23\u0e39\u0e1b\u0e41\u0e1a\u0e1a\u0e01\u0e32\u0e23\u0e0a\u0e14\u0e40\u0e0a\u0e22\u0e17\u0e35\u0e48\u0e44\u0e14\u0e49\u0e23\u0e31\u0e1a\u0e2b\u0e23\u0e37\u0e2d\u0e01\u0e33\u0e25\u0e31\u0e07\u0e17\u0e35\u0e48\u0e08\u0e30\u0e44\u0e14\u0e49\u0e23\u0e31\u0e1a\u0e08\u0e32\u0e01\u0e41\u0e2b\u0e25\u0e48\u0e07\u0e2d\u0e37\u0e48\u0e19' >\u0e01\u0e23\u0e38\u0e13\u0e32\u0e40\u0e25\u0e37\u0e2d\u0e01\u0e23\u0e39\u0e1b\u0e41\u0e1a\u0e1a\u0e01\u0e32\u0e23\u0e0a\u0e14\u0e40\u0e0a\u0e22\u0e17\u0e35\u0e48\u0e44\u0e14\u0e49\u0e23\u0e31\u0e1a\u0e2b\u0e23\u0e37\u0e2d\u0e01\u0e33\u0e25\u0e31\u0e07\u0e17\u0e35\u0e48\u0e08\u0e30\u0e44\u0e14\u0e49\u0e23\u0e31\u0e1a\u0e08\u0e32\u0e01\u0e41\u0e2b\u0e25\u0e48\u0e07\u0e2d\u0e37\u0e48\u0e19<\/option><option value='\u0e04\u0e27\u0e32\u0e21\u0e04\u0e38\u0e49\u0e21\u0e04\u0e23\u0e2d\u0e07\u0e08\u0e32\u0e01\u0e1b\u0e23\u0e30\u0e01\u0e31\u0e19 \u0e2b\u0e23\u0e37\u0e2d\u0e2a\u0e27\u0e31\u0e2a\u0e14\u0e34\u0e01\u0e32\u0e23\u0e2d\u0e37\u0e48\u0e19 \/ Coverage from other insurance\/benefit' >\u0e04\u0e27\u0e32\u0e21\u0e04\u0e38\u0e49\u0e21\u0e04\u0e23\u0e2d\u0e07\u0e08\u0e32\u0e01\u0e1b\u0e23\u0e30\u0e01\u0e31\u0e19 \u0e2b\u0e23\u0e37\u0e2d\u0e2a\u0e27\u0e31\u0e2a\u0e14\u0e34\u0e01\u0e32\u0e23\u0e2d\u0e37\u0e48\u0e19 \/ Coverage from other insurance\/benefit<\/option><option value='\u0e23\u0e2d\u0e01\u0e32\u0e23\u0e22\u0e37\u0e19\u0e22\u0e31\u0e19\u0e04\u0e37\u0e19\u0e40\u0e07\u0e34\u0e19 \u0e04\u0e27\u0e32\u0e21\u0e04\u0e38\u0e49\u0e21\u0e04\u0e23\u0e2d\u0e07\u0e08\u0e32\u0e01\u0e41\u0e2b\u0e25\u0e48\u0e07\u0e2d\u0e37\u0e48\u0e19\u0e2a\u0e27\u0e31\u0e2a\u0e14\u0e34\u0e01\u0e32\u0e23\u0e2d\u0e37\u0e48\u0e19 \u0e2b\u0e23\u0e37\u0e2d\u0e1c\u0e39\u0e49\u0e43\u0e2b\u0e49\u0e1a\u0e23\u0e34\u0e01\u0e32\u0e23 \/ Awaiting refund\/decision from any other source' >\u0e23\u0e2d\u0e01\u0e32\u0e23\u0e22\u0e37\u0e19\u0e22\u0e31\u0e19\u0e04\u0e37\u0e19\u0e40\u0e07\u0e34\u0e19 \u0e04\u0e27\u0e32\u0e21\u0e04\u0e38\u0e49\u0e21\u0e04\u0e23\u0e2d\u0e07\u0e08\u0e32\u0e01\u0e41\u0e2b\u0e25\u0e48\u0e07\u0e2d\u0e37\u0e48\u0e19\u0e2a\u0e27\u0e31\u0e2a\u0e14\u0e34\u0e01\u0e32\u0e23\u0e2d\u0e37\u0e48\u0e19 \u0e2b\u0e23\u0e37\u0e2d\u0e1c\u0e39\u0e49\u0e43\u0e2b\u0e49\u0e1a\u0e23\u0e34\u0e01\u0e32\u0e23 \/ Awaiting refund\/decision from any other source<\/option><option value='\u0e44\u0e21\u0e48\u0e44\u0e14\u0e49\u0e23\u0e31\u0e1a\u0e01\u0e32\u0e23\u0e0a\u0e14\u0e40\u0e0a\u0e22\u0e43\u0e14\u0e46 \/ No compensation' >\u0e44\u0e21\u0e48\u0e44\u0e14\u0e49\u0e23\u0e31\u0e1a\u0e01\u0e32\u0e23\u0e0a\u0e14\u0e40\u0e0a\u0e22\u0e43\u0e14\u0e46 \/ No compensation<\/option><\/select><\/div><\/div><fieldset id=\"field_1_132\"  class=\"gfield gfield--type-list gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_132\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >\u0e04\u0e27\u0e32\u0e21\u0e04\u0e38\u0e49\u0e21\u0e04\u0e23\u0e2d\u0e07\u0e08\u0e32\u0e01\u0e1b\u0e23\u0e30\u0e01\u0e31\u0e19 \u0e2b\u0e23\u0e37\u0e2d\u0e2a\u0e27\u0e31\u0e2a\u0e14\u0e34\u0e01\u0e32\u0e23\u0e2d\u0e37\u0e48\u0e19 \/ Coverage from other insurance\/benefit<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">\u0e41\u0e2b\u0e25\u0e48\u0e07\u0e17\u0e35\u0e48\u0e44\u0e14\u0e49\u0e23\u0e31\u0e1a \/ Source<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">\u0e08\u0e33\u0e19\u0e27\u0e19 \/ Amount<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_132_cell1 gform-grid-col' data-label='\u0e41\u0e2b\u0e25\u0e48\u0e07\u0e17\u0e35\u0e48\u0e44\u0e14\u0e49\u0e23\u0e31\u0e1a \/ Source'><input aria-invalid='false' aria-required=\"true\"  aria-label='\u0e41\u0e2b\u0e25\u0e48\u0e07\u0e17\u0e35\u0e48\u0e44\u0e14\u0e49\u0e23\u0e31\u0e1a \/ Source, Row 1' data-aria-label-template='\u0e41\u0e2b\u0e25\u0e48\u0e07\u0e17\u0e35\u0e48\u0e44\u0e14\u0e49\u0e23\u0e31\u0e1a \/ Source, Row {0}' type='text' name='input_132[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_132_cell2 gform-grid-col' data-label='\u0e08\u0e33\u0e19\u0e27\u0e19 \/ Amount'><input aria-invalid='false' aria-required=\"true\"  aria-label='\u0e08\u0e33\u0e19\u0e27\u0e19 \/ Amount, Row 1' data-aria-label-template='\u0e08\u0e33\u0e19\u0e27\u0e19 \/ Amount, Row {0}' type='text' name='input_132[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_132_cell3 gform-grid-col' data-label='\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency'><input aria-invalid='false' aria-required=\"true\"  aria-label='\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency, Row 1' data-aria-label-template='\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency, Row {0}' type='text' name='input_132[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_133\"  class=\"gfield gfield--type-list gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_133\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >\u0e40\u0e07\u0e34\u0e19\u0e2a\u0e14 \u0e40\u0e07\u0e34\u0e19\u0e42\u0e2d\u0e19\u0e40\u0e02\u0e49\u0e32\u0e1a\u0e31\u0e0d\u0e0a\u0e35 \u0e01\u0e32\u0e23\u0e04\u0e37\u0e19\u0e40\u0e07\u0e34\u0e19 \u0e08\u0e32\u0e01\u0e1c\u0e39\u0e49\u0e43\u0e2b\u0e49\u0e1a\u0e23\u0e34\u0e01\u0e32\u0e23 \/ Cash, bank transfer or refund from provider<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">\u0e08\u0e33\u0e19\u0e27\u0e19 \/ Amount<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_133_cell1 gform-grid-col' data-label='\u0e08\u0e33\u0e19\u0e27\u0e19 \/ Amount'><input aria-invalid='false' aria-required=\"true\"  aria-label='\u0e08\u0e33\u0e19\u0e27\u0e19 \/ Amount, Row 1' data-aria-label-template='\u0e08\u0e33\u0e19\u0e27\u0e19 \/ Amount, Row {0}' type='text' name='input_133[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_133_cell2 gform-grid-col' data-label='\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency'><input aria-invalid='false' aria-required=\"true\"  aria-label='\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency, Row 1' data-aria-label-template='\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency, Row {0}' type='text' name='input_133[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_134\"  class=\"gfield gfield--type-list gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_134\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >\u0e23\u0e2d\u0e01\u0e32\u0e23\u0e22\u0e37\u0e19\u0e22\u0e31\u0e19\u0e04\u0e37\u0e19\u0e40\u0e07\u0e34\u0e19 \u0e04\u0e27\u0e32\u0e21\u0e04\u0e38\u0e49\u0e21\u0e04\u0e23\u0e2d\u0e07\u0e08\u0e32\u0e01\u0e41\u0e2b\u0e25\u0e48\u0e07\u0e2d\u0e37\u0e48\u0e19\u0e2a\u0e27\u0e31\u0e2a\u0e14\u0e34\u0e01\u0e32\u0e23\u0e2d\u0e37\u0e48\u0e19 \u0e2b\u0e23\u0e37\u0e2d\u0e1c\u0e39\u0e49\u0e43\u0e2b\u0e49\u0e1a\u0e23\u0e34\u0e01\u0e32\u0e23 \/ Awaiting refund\/decision from any other source<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">\u0e41\u0e2b\u0e25\u0e48\u0e07\u0e17\u0e35\u0e48\u0e44\u0e14\u0e49\u0e23\u0e31\u0e1a \/ Source<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">\u0e08\u0e33\u0e19\u0e27\u0e19\u0e2b\u0e23\u0e37\u0e2d\u0e21\u0e39\u0e25\u0e04\u0e48\u0e32 \/ Amount or Value<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_134_cell1 gform-grid-col' data-label='\u0e41\u0e2b\u0e25\u0e48\u0e07\u0e17\u0e35\u0e48\u0e44\u0e14\u0e49\u0e23\u0e31\u0e1a \/ Source'><input aria-invalid='false' aria-required=\"true\"  aria-label='\u0e41\u0e2b\u0e25\u0e48\u0e07\u0e17\u0e35\u0e48\u0e44\u0e14\u0e49\u0e23\u0e31\u0e1a \/ Source, Row 1' data-aria-label-template='\u0e41\u0e2b\u0e25\u0e48\u0e07\u0e17\u0e35\u0e48\u0e44\u0e14\u0e49\u0e23\u0e31\u0e1a \/ Source, Row {0}' type='text' name='input_134[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_134_cell2 gform-grid-col' data-label='\u0e08\u0e33\u0e19\u0e27\u0e19\u0e2b\u0e23\u0e37\u0e2d\u0e21\u0e39\u0e25\u0e04\u0e48\u0e32 \/ Amount or Value'><input aria-invalid='false' aria-required=\"true\"  aria-label='\u0e08\u0e33\u0e19\u0e27\u0e19\u0e2b\u0e23\u0e37\u0e2d\u0e21\u0e39\u0e25\u0e04\u0e48\u0e32 \/ Amount or Value, Row 1' data-aria-label-template='\u0e08\u0e33\u0e19\u0e27\u0e19\u0e2b\u0e23\u0e37\u0e2d\u0e21\u0e39\u0e25\u0e04\u0e48\u0e32 \/ Amount or Value, Row {0}' type='text' name='input_134[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_134_cell3 gform-grid-col' data-label='\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency'><input aria-invalid='false' aria-required=\"true\"  aria-label='\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency, Row 1' data-aria-label-template='\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency, Row {0}' type='text' name='input_134[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_135\"  class=\"gfield gfield--type-list gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_135\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >\u0e2d\u0e37\u0e48\u0e19\u0e46 \u0e42\u0e1b\u0e23\u0e14\u0e23\u0e30\u0e1a\u0e38 \/ Other, please specify<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">\u0e23\u0e32\u0e22\u0e01\u0e32\u0e23 \/ List<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">\u0e08\u0e33\u0e19\u0e27\u0e19\u0e2b\u0e23\u0e37\u0e2d\u0e21\u0e39\u0e25\u0e04\u0e48\u0e32 \/ Amount or Value<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_135_cell1 gform-grid-col' data-label='\u0e23\u0e32\u0e22\u0e01\u0e32\u0e23 \/ List'><input aria-invalid='false' aria-required=\"true\"  aria-label='\u0e23\u0e32\u0e22\u0e01\u0e32\u0e23 \/ List, Row 1' data-aria-label-template='\u0e23\u0e32\u0e22\u0e01\u0e32\u0e23 \/ List, Row {0}' type='text' name='input_135[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_135_cell2 gform-grid-col' data-label='\u0e08\u0e33\u0e19\u0e27\u0e19\u0e2b\u0e23\u0e37\u0e2d\u0e21\u0e39\u0e25\u0e04\u0e48\u0e32 \/ Amount or Value'><input aria-invalid='false' aria-required=\"true\"  aria-label='\u0e08\u0e33\u0e19\u0e27\u0e19\u0e2b\u0e23\u0e37\u0e2d\u0e21\u0e39\u0e25\u0e04\u0e48\u0e32 \/ Amount or Value, Row 1' data-aria-label-template='\u0e08\u0e33\u0e19\u0e27\u0e19\u0e2b\u0e23\u0e37\u0e2d\u0e21\u0e39\u0e25\u0e04\u0e48\u0e32 \/ Amount or Value, Row {0}' type='text' name='input_135[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_135_cell3 gform-grid-col' data-label='\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency'><input aria-invalid='false' aria-required=\"true\"  aria-label='\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency, Row 1' data-aria-label-template='\u0e2b\u0e19\u0e48\u0e27\u0e22\u0e40\u0e07\u0e34\u0e19 \/ Currency, Row {0}' type='text' name='input_135[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_107' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_107' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"4\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"4\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_4' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_4' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_1_92\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_92\"><h3 class=\"gsection_title\">4. \u0e01\u0e32\u0e23\u0e08\u0e48\u0e32\u0e22\u0e40\u0e07\u0e34\u0e19 \u0e41\u0e25\u0e30\u0e01\u0e32\u0e23\u0e22\u0e37\u0e19\u0e22\u0e31\u0e19 \/ Claim Payment Method and Declaration<\/h3><\/div><div id=\"field_1_93\"  class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_93\"><label class='gfield_label gform-field-label' for='input_1_93' >\u0e0a\u0e37\u0e48\u0e2d\u0e1a\u0e31\u0e0d\u0e0a\u0e35 \/ Account Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_93' id='input_1_93' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_94\"  class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_94\"><label class='gfield_label gform-field-label' for='input_1_94' >\u0e2b\u0e21\u0e32\u0e22\u0e40\u0e25\u0e02\u0e1a\u0e31\u0e0d\u0e0a\u0e35 \/ Account Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_94' id='input_1_94' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_95\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_95\"><label class='gfield_label gform-field-label' for='input_1_95' >\u0e0a\u0e37\u0e48\u0e2d\u0e18\u0e19\u0e32\u0e04\u0e32\u0e23 \/ Name of Bank<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_95' id='input_1_95' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='\u0e01\u0e23\u0e38\u0e13\u0e32\u0e40\u0e25\u0e37\u0e2d\u0e01\u0e0a\u0e37\u0e48\u0e2d\u0e18\u0e19\u0e32\u0e04\u0e32\u0e23' >\u0e01\u0e23\u0e38\u0e13\u0e32\u0e40\u0e25\u0e37\u0e2d\u0e01\u0e0a\u0e37\u0e48\u0e2d\u0e18\u0e19\u0e32\u0e04\u0e32\u0e23<\/option><option value='Bangkok Bank' >Bangkok Bank<\/option><option value='Bank of Ayudhya' >Bank of Ayudhya<\/option><option value='Krung Thai Bank' >Krung Thai Bank<\/option><option value='Kiatnakin Bank' >Kiatnakin Bank<\/option><option value='Kasikorn Bank' >Kasikorn Bank<\/option><option value='The Siam Commercial Bank' >The Siam Commercial Bank<\/option><option value='Government Savings Bank' >Government Savings Bank<\/option><option value='TMB Thanachart Bank' >TMB Thanachart Bank<\/option><option value='Citibank' >Citibank<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_1_96\"  class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_96\"><label class='gfield_label gform-field-label' for='input_1_96' >\u0e0a\u0e37\u0e48\u0e2d\u0e18\u0e19\u0e32\u0e04\u0e32\u0e23 \/ Name of Bank<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_96' id='input_1_96' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_97\"  class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_97\"><label class='gfield_label gform-field-label' for='input_1_97' >Swift Code<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_97' id='input_1_97' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_98\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_98\"><label class='gfield_label gform-field-label' for='input_1_98' >\u0e0a\u0e37\u0e48\u0e2d\u0e2a\u0e32\u0e02\u0e32 \/ Bank Branch Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_98' id='input_1_98' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_112\"  class=\"gfield gfield--type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_112\"><label class='gfield_label gform-field-label' for='gform_browse_button_1_112' >\u0e2a\u0e33\u0e40\u0e19\u0e32\u0e2b\u0e19\u0e49\u0e32\u0e41\u0e23\u0e01\u0e2a\u0e21\u0e38\u0e14\u0e1a\u0e31\u0e0d\u0e0a\u0e35\u0e18\u0e19\u0e32\u0e04\u0e32\u0e23 \/ Bank account information page<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_1_112' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_1_112&quot;,&quot;container&quot;:&quot;gform_multifile_upload_1_112&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_1_112&quot;,&quot;filelist&quot;:&quot;gform_preview_1_112&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/?gf_page=1005716fe3bdff0&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/allianz-assistance.co.th\\\/travel\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,jpeg&quot;}],&quot;max_file_size&quot;:&quot;5242880b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:1,&quot;field_id&quot;:112},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_1_112&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_1_112' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span 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