<?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>09:11:58.082</FormCreationHour>
		<AttestationStatus>0</AttestationStatus>
		<TypeForm>SU</TypeForm>
		<DclInformation>
			<LanguageCodePdf>1</LanguageCodePdf>
		</DclInformation>
		<RiskIdentification>
			<IdentificationOfRisk>002</IdentificationOfRisk>
		</RiskIdentification>
		<EmployerDeclarationLink>
			<NOSSRegistrationNbr>070285229</NOSSRegistrationNbr>
			<Trusteeship>0</Trusteeship>
			<CompanyID>0</CompanyID>
			<NaturalPerson>
				<NaturalPersonSequenceNbr>1</NaturalPersonSequenceNbr>
				<INSS>82020209727</INSS>
				<WorkerStreet>Rue de Menin</WorkerStreet>
				<WorkerHouseNbr>235</WorkerHouseNbr>
				<WorkerZIPCode>7700</WorkerZIPCode>
				<WorkerCity>Mouscron</WorkerCity>
				<WorkerCountry>150</WorkerCountry>
				<WorkerRecordLink>
					<EmployerClass>097</EmployerClass>
					<WorkerCode>999</WorkerCode>
					<OccupationLink>
						<OccupationStartingDate>1967-08-13</OccupationStartingDate>
						<OccupationEndingDate>1967-08-13</OccupationEndingDate>
						<JointCommissionNbr>322</JointCommissionNbr>
						<WorkingDaysSystem>500</WorkingDaysSystem>
						<MeanWorkingHours>3900</MeanWorkingHours>
						<RefMeanWorkingHours>4800</RefMeanWorkingHours>
						<Retired>0</Retired>
						<ContractType>1</ContractType>
						<RemunMethod>1</RemunMethod>
						<SupplementaryCalculationBaseAllowance>
							<EndYearBonusCode>4</EndYearBonusCode>
							<EndYearBonusAmount>2344</EndYearBonusAmount>
							<EndYearBonusValue>4253</EndYearBonusValue>
							<EndYearBonusHours>456</EndYearBonusHours>
						</SupplementaryCalculationBaseAllowance>
						<CalculationBaseAllowance>
							<RemunerationTimeUnit>1</RemunerationTimeUnit>
							<PieceTaskServicesCommissionRemunerationBasisAmount>0003000000</PieceTaskServicesCommissionRemunerationBasisAmount>
						</CalculationBaseAllowance>
						<LostWorkingHours>
							<LooseWorkHoursNumber>0500</LooseWorkHoursNumber>
							<SalaryLossOfLooseWorkHours>45400</SalaryLossOfLooseWorkHours>
						</LostWorkingHours>
						<IndustrialAccidentDescription>
							<Accident>
								<AccidentDate>2003-02-14</AccidentDate>
								<AccidentHourKnown>1</AccidentHourKnown>
								<AccidentHour>1830</AccidentHour>
								<AccidentNature>0</AccidentNature>
								<WorkingStartHour>1200</WorkingStartHour>
								<WorkingStopHour>2030</WorkingStopHour>
								<EnvironmentAtAccidentMoment>atelier</EnvironmentAtAccidentMoment>
								<AccidentNotificationDate>2003-02-14</AccidentNotificationDate>
								<AccidentNotificationHour>1000</AccidentNotificationHour>
								<LastEventCode>12</LastEventCode>
								<ObjectCode>00.00</ObjectCode>
								<AccidentDescription>accident de la route</AccidentDescription>
								<EconomicConsequences>
									<AccidentConsequences>2</AccidentConsequences>
									<ActivityStopDate>2003-02-14</ActivityStopDate>
									<ActivityStopHour>1000</ActivityStopHour>
									<WorkRecoveryDateKnown>1</WorkRecoveryDateKnown>
									<WorkRecovery>
										<WorkRecoveryDate>2003-02-17</WorkRecoveryDate>
									</WorkRecovery>
								</EconomicConsequences>
								<MedicalConsequences>
									<InjuriesNatureCode>80</InjuriesNatureCode>
									<InjuriesNatureDescription>pied</InjuriesNatureDescription>
									<InjuriesPlaceCode>52</InjuriesPlaceCode>
									<InjuriesPlaceDescription>bras</InjuriesPlaceDescription>
								</MedicalConsequences>
								<AccidentPlaceInformation>
									<AccidentPlaceCode>3</AccidentPlaceCode>
									<YardTicket>340-008R0PE-00-M</YardTicket>
									<AccidentPlaceZIPCode>1000</AccidentPlaceZIPCode>
									<AccidentPlaceCountry>150</AccidentPlaceCountry>
								</AccidentPlaceInformation>
							</Accident>
							<Victim>
								<VictimLanguageCode>2</VictimLanguageCode>
								<Address>
									<Street>Schildershof</Street>
									<HouseNbr>27</HouseNbr>
									<ZIPCode>3511</ZIPCode>
									<City>Kuringen</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>M12/12456</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>2005-02-14</ServiceEndingDate>
									<TempWorker>0</TempWorker>
									<DimonaNbr>500000879440</DimonaNbr>
									<ContractDurationCode>1</ContractDurationCode>
								</Work>
							</Victim>
							<Insurance>
								<InsurerId>0114</InsurerId>
								<PolicyIdentifier>AT0023207001</PolicyIdentifier>
								<SubdivisionUsage>0</SubdivisionUsage>
							</Insurance>
						</IndustrialAccidentDescription>
					</OccupationLink>
				</WorkerRecordLink>
			</NaturalPerson>
		</EmployerDeclarationLink>
	</Form>
</AOAT001>