Claim Form

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PERSONAL INFORMATION
Salutation* 
First Name* 
Last Name* 
Email* 
Contact Number* 
   
RESERVATION INFORMATION  
Reservation Number* 
Check-in Date*  dd/mm/yyyy
Check-out Date*  dd/mm/yyyy
Our Internet Rate* 
Currency*  e.g.: USD, IDR
   
COMPARISON RATE  
Comparison Rate* 
Currency*  e.g.: USD, IDR
URL of the website* 
Screenshots*
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Comments* 

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