<?xml version='1.0' encoding='UTF-8'?>
<AOAT001 xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:noNamespaceSchemaLocation="AOAT001_20261.xsd">
	<Form>
		<Identification>AOAT001</Identification>
		<FormCreationDate>2022-08-11</FormCreationDate>
		<FormCreationHour>09:10:58.082</FormCreationHour>
		<AttestationStatus>0</AttestationStatus>
		<TypeForm>SU</TypeForm>
		<DclInformation>
			<LanguageCodePdf>1</LanguageCodePdf>
		</DclInformation>
		<RiskIdentification>
			<IdentificationOfRisk>001</IdentificationOfRisk>
		</RiskIdentification>
		<EmployerDeclarationLink>
			<NOSSRegistrationNbr>141137377</NOSSRegistrationNbr>
			<Trusteeship>0</Trusteeship>
			<CompanyID>1111111111</CompanyID>
			<NaturalPerson>
				<NaturalPersonSequenceNbr>1</NaturalPersonSequenceNbr>
				<INSS>57040610511</INSS>
				<WorkerStreet>rue d'Arlon</WorkerStreet>
				<WorkerHouseNbr>56</WorkerHouseNbr>
				<WorkerZIPCode>4500</WorkerZIPCode>
				<WorkerCity>Huy</WorkerCity>
				<WorkerCountry>150</WorkerCountry>
				<WorkerRecordLink>
					<EmployerClass>123</EmployerClass>
					<WorkerCode>015</WorkerCode>
					<OccupationLink>
						<OccupationStartingDate>1999-04-01</OccupationStartingDate>
						<JointCommissionNbr>124</JointCommissionNbr>
						<WorkingDaysSystem>500</WorkingDaysSystem>
						<MeanWorkingHours>3800</MeanWorkingHours>
						<RefMeanWorkingHours>3800</RefMeanWorkingHours>
						<Retired>0</Retired>
						<ContractType>1</ContractType>
						<RemunMethod>1</RemunMethod>
						<SupplementaryCalculationBaseAllowance>
							<EndYearBonusCode>4</EndYearBonusCode>
							<EndYearBonusAmount>2344</EndYearBonusAmount>
							<EndYearBonusValue>4253</EndYearBonusValue>
							<EndYearBonusHours>456</EndYearBonusHours>
							<Advantage>00001300</Advantage>
							<AdvantageDescription>ster</AdvantageDescription>
						</SupplementaryCalculationBaseAllowance>
						<CalculationBaseAllowance>
							<RemunerationTimeUnit>2</RemunerationTimeUnit>
							<RemunerationBasisAmount>0000031200</RemunerationBasisAmount>
						</CalculationBaseAllowance>
						<LostWorkingHours>
							<LooseWorkHoursNumber>0500</LooseWorkHoursNumber>
							<SalaryLossOfLooseWorkHours>45400</SalaryLossOfLooseWorkHours>
						</LostWorkingHours>
						<FunctionChange>
							<HasChangedOfFunction>1</HasChangedOfFunction>
							<FunctionLastChange>2002-06-01</FunctionLastChange>
						</FunctionChange>
						<IndustrialAccidentDescription>
							<Accident>
								<AccidentDate>2003-09-14</AccidentDate>
								<AccidentHourKnown>1</AccidentHourKnown>
								<AccidentHour>1030</AccidentHour>
								<AccidentNature>0</AccidentNature>
								<WorkingStationCode>1</WorkingStationCode>
								<WorkingStartHour>0800</WorkingStartHour>
								<BreakHourFrom>1200</BreakHourFrom>
								<BreakHourUntil>1230</BreakHourUntil>
								<WorkingStopHour>1600</WorkingStopHour>
								<EnvironmentAtAccidentMoment>Particuliere woning</EnvironmentAtAccidentMoment>
								<AccidentNotificationDate>2003-09-14</AccidentNotificationDate>
								<AccidentNotificationHour>1105</AccidentNotificationHour>
								<TypeOfWork>Nieuwbouw van een woning</TypeOfWork>
								<ActivityAtAccidentMoment>Aannemen van een kuip mortel</ActivityAtAccidentMoment>
								<WhichEvents>Abnormale beweging door de kraanman</WhichEvents>
								<LastEventCode>20</LastEventCode>
								<ObjectCode>01.00</ObjectCode>
								<AccidentCardYear>2003</AccidentCardYear>
								<AccidentCardSequenceNumber>456</AccidentCardSequenceNumber>
								<EconomicConsequences>
									<AccidentConsequences>6</AccidentConsequences>
									<ActivityStopDate>2003-09-14</ActivityStopDate>
									<ActivityStopHour>1030</ActivityStopHour>
									<TemporaryWorkIncapability>42</TemporaryWorkIncapability>
									<WorkRecoveryDateKnown>0</WorkRecoveryDateKnown>
								</EconomicConsequences>
								<MedicalConsequences>
									<HowInjured>Verplettering van de hand tussen kuip en muur</HowInjured>
									<InjuriesNatureCode>10</InjuriesNatureCode>
									<InjuriesNatureDescription>Open fractuur en schaafwonden</InjuriesNatureDescription>
									<InjuriesPlaceCode>43</InjuriesPlaceCode>
									<InjuriesPlaceDescription>Rechterhand en arm</InjuriesPlaceDescription>
									<InternalAdministerCare>0</InternalAdministerCare>
									<ExternalAdministerCare>1</ExternalAdministerCare>
									<ExternalDoctorInterventionDate>2003-09-14</ExternalDoctorInterventionDate>
									<ExternalDoctorInterventionHour>0830</ExternalDoctorInterventionHour>
									<HospitalAdministerCare>1</HospitalAdministerCare>
									<HospitalInterventionDate>2003-09-14</HospitalInterventionDate>
									<HospitalInterventionHour>1100</HospitalInterventionHour>
									<Doctor>
										<ExternalDoctorId>10817181930</ExternalDoctorId>
										<ExternalDoctorName>CASTELEYN</ExternalDoctorName>
										<ExternalDoctorFirstName>LIEVE</ExternalDoctorFirstName>
									</Doctor>
									<Hospital>
										<HospitalId>71000238</HospitalId>
										<HospitalName>hopital général</HospitalName>
										<Address>
											<Street>haite</Street>
											<HouseNbr>556</HouseNbr>
											<ZIPCode>4500</ZIPCode>
											<City>huy</City>
											<Country>150</Country>
											<AddressDescription>
												<TypeOfAddress>5</TypeOfAddress>
											</AddressDescription>
										</Address>
									</Hospital>
								</MedicalConsequences>
								<Classification>
									<InternalRiskCode>124</InternalRiskCode>
								</Classification>
								<Classification>
									<InternalRiskCode>231</InternalRiskCode>
								</Classification>
								<AccidentPlaceInformation>
									<AccidentPlaceCode>2</AccidentPlaceCode>
									<TrafficAccident>1</TrafficAccident>
									<AccidentPlaceStreet>Ternat</AccidentPlaceStreet>
									<AccidentPlaceHouseNbr>15</AccidentPlaceHouseNbr>
									<AccidentPlaceZIPCode>1742</AccidentPlaceZIPCode>
									<AccidentPlaceCity>Ternat</AccidentPlaceCity>
									<AccidentPlaceCountry>150</AccidentPlaceCountry>
								</AccidentPlaceInformation>
							</Accident>
							<Victim>
								<VictimLanguageCode>1</VictimLanguageCode>
								<EmployerRelatednessDegree>1</EmployerRelatednessDegree>
								<VictimAccountNumber>BE68539007547034</VictimAccountNumber>
								<AccountNbrFormat>2</AccountNbrFormat>
								<BankIdentifierCode>BBRUBEBB</BankIdentifierCode>
								<VictimPhoneNumber>02-1523698</VictimPhoneNumber>
								<Address>
									<Street>Leopoldlaan</Street>
									<HouseNbr>20</HouseNbr>
									<ZIPCode>1050</ZIPCode>
									<City>Brussel</City>
									<Country>150</Country>
									<AddressDescription>
										<TypeOfAddress>1</TypeOfAddress>
									</AddressDescription>
								</Address>
								<Mutuality>
									<MutualityCode>107</MutualityCode>
									<MutualityName>Fédération M.R.B. - Fédération mutualiste d'Assurance maladie, tous Risques en Belgique</MutualityName>
									<MutualityAffiliationId>123456</MutualityAffiliationId>
									<Address>
										<Street>Boulevard Saint-Lazare</Street>
										<HouseNbr>2</HouseNbr>
										<PostBox>2</PostBox>
										<ZIPCode>1210</ZIPCode>
										<City>Saint-Josse-Ten-Noode</City>
										<Country>150</Country>
										<AddressDescription>
											<TypeOfAddress>4</TypeOfAddress>
										</AddressDescription>
									</Address>
								</Mutuality>
								<Work>
									<VictimWorkingAtOtherEmployer>0</VictimWorkingAtOtherEmployer>
									<ServiceEndingDateKnown>1</ServiceEndingDateKnown>
									<ServiceEndingDate>2004-12-13</ServiceEndingDate>
									<TempWorker>1</TempWorker>
									<DimonaNbr>500000879642</DimonaNbr>
									<FunctionCode>712</FunctionCode>
									<NormalJob>Metser</NormalJob>
									<ContractDurationCode>1</ContractDurationCode>
									<SeniorityUsualProfessionCode>1</SeniorityUsualProfessionCode>
									<UsingEmployer>
										<UsingEmployerCompanyID>1111111111</UsingEmployerCompanyID>
									</UsingEmployer>
								</Work>
								<ProtectionMeansInformation>
									<ProtectionMeansCode>02</ProtectionMeansCode>
									<ProtectionMeansCode>03</ProtectionMeansCode>
									<ProtectionMeansCode>04</ProtectionMeansCode>
									<ProtectionMeansCode>06</ProtectionMeansCode>
									<ProtectionMeansCode>10</ProtectionMeansCode>
									<ProtectionMeansCode>11</ProtectionMeansCode>
									<ProtectionMeansCode>12</ProtectionMeansCode>
									<ProtectionMeansCode>14</ProtectionMeansCode>
									<Comment>Autre Moyens de Protection</Comment>
								</ProtectionMeansInformation>
							</Victim>
							<Employer>
								<AccountNumber>BE988091011476341</AccountNumber>
								<AccountNbrFormat>1</AccountNbrFormat>
								<ContactPhoneNumber>02-111111</ContactPhoneNumber>
								<LocalUnitID>2001497406</LocalUnitID>
								<PreventionMeasure>
									<PreventionMeasureDescription>campagne</PreventionMeasureDescription>
									<PreventionMeasureCode>21</PreventionMeasureCode>
								</PreventionMeasure>
								<PreventionMeasure>
									<PreventionMeasureDescription>port du casque</PreventionMeasureDescription>
									<PreventionMeasureCode>32</PreventionMeasureCode>
								</PreventionMeasure>
							</Employer>
							<Insurance>
								<InsurerId>1018</InsurerId>
								<PolicyIdentifier>123456789</PolicyIdentifier>
								<SubdivisionUsage>1</SubdivisionUsage>
								<SubdivisionNumber>45</SubdivisionNumber>
								<VictimTariffCode>456</VictimTariffCode>
							</Insurance>
							<Presence>
								<VerbalLawsuitEstablished>1</VerbalLawsuitEstablished>
								<Witnesses>1</Witnesses>
								<ThirdResponsables>1</ThirdResponsables>
								<VerbalLawsuit>
									<VerbalLawsuitPlace>louvain</VerbalLawsuitPlace>
									<VerbalLawsuitAuthority>POLICE</VerbalLawsuitAuthority>
									<VerbalLawsuitDate>2003-09-14</VerbalLawsuitDate>
									<VerbalLawsuitId>102356</VerbalLawsuitId>
								</VerbalLawsuit>
								<Witness>
									<TypeOfWitness>1</TypeOfWitness>
									<CoordinatesWitness>
										<WitnessName>Duchemin</WitnessName>
										<WitnessFirstName>Jaques</WitnessFirstName>
										<Address>
											<Street>haute</Street>
											<HouseNbr>3</HouseNbr>
											<ZIPCode>5000</ZIPCode>
											<City>Namur</City>
											<Country>150</Country>
											<AddressDescription>
												<TypeOfAddress>2</TypeOfAddress>
											</AddressDescription>
										</Address>
									</CoordinatesWitness>
								</Witness>
								<ThirdResponsable>
									<ThirdResponsableKnown>1</ThirdResponsableKnown>
									<CoordinatesThirdResponsable>
										<ThirdResponsableName>martin</ThirdResponsableName>
										<ThirdResponsableFirstName>julien</ThirdResponsableFirstName>
										<Address>
											<Street>des bois</Street>
											<HouseNbr>3</HouseNbr>
											<ZIPCode>4500</ZIPCode>
											<City>huy</City>
											<Country>150</Country>
											<AddressDescription>
												<TypeOfAddress>2</TypeOfAddress>
											</AddressDescription>
										</Address>
									</CoordinatesThirdResponsable>
									<InsuranceThirdResponsable>
										<ThirdResponsablePolicyIdentifier>5555</ThirdResponsablePolicyIdentifier>
										<ThirdResponsableInsurerName>LHYU</ThirdResponsableInsurerName>
										<Address>
											<Street>de l'industrie</Street>
											<HouseNbr>6</HouseNbr>
											<ZIPCode>6000</ZIPCode>
											<City>charleroi</City>
											<Country>150</Country>
											<AddressDescription>
												<TypeOfAddress>4</TypeOfAddress>
											</AddressDescription>
										</Address>
									</InsuranceThirdResponsable>
								</ThirdResponsable>
							</Presence>
						</IndustrialAccidentDescription>
					</OccupationLink>
				</WorkerRecordLink>
			</NaturalPerson>
		</EmployerDeclarationLink>
	</Form>
</AOAT001>