<?xml version='1.0' encoding='UTF-8'?>
<ZIMA001 xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:noNamespaceSchemaLocation="ZIMA001_20254.xsd">
	<Form>
		<Identification>ZIMA001</Identification>
		<FormCreationDate>2021-11-16</FormCreationDate>
		<FormCreationHour>09:28:13.084</FormCreationHour>
		<AttestationStatus>0</AttestationStatus>
		<TypeForm>FA</TypeForm>
		<CoordinatesContactPerson>
			<Name>Nom</Name>
			<FirstName>Lauren</FirstName>
			<Communication>
				<EmailAddress>Lauren.Nom@skynet.be</EmailAddress>
			</Communication>
		</CoordinatesContactPerson>
		<DclInformation>
			<LanguageCodePdf>1</LanguageCodePdf>
		</DclInformation>
		<RiskIdentification>
			<IdentificationOfRisk>001</IdentificationOfRisk>
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		<Reference>
			<ReferenceType>5</ReferenceType>
			<ReferenceOrigin>2</ReferenceOrigin>
			<ReferenceNbr>340000103H01U</ReferenceNbr>
		</Reference>
		<Reference>
			<ReferenceType>1</ReferenceType>
			<ReferenceOrigin>1</ReferenceOrigin>
			<ReferenceNbr>2005005</ReferenceNbr>
		</Reference>
		<RiskDetail>
			<RiskStartingDate>2021-05-06</RiskStartingDate>
		</RiskDetail>
		<PreventionService>
			<CompanyID>0</CompanyID>
			<Denomination>Externe preventiedienst</Denomination>
			<CoordinatesContactPerson>
				<Name>Janssens</Name>
				<FirstName>Jan</FirstName>
				<Communication>
					<PhoneNbr>022222222</PhoneNbr>
					<EmailAddress>janjanssens@email.be</EmailAddress>
				</Communication>
			</CoordinatesContactPerson>
		</PreventionService>
		<EmployerDeclaration>
			<Quarter>20211</Quarter>
			<NOSSRegistrationNbr>141137377</NOSSRegistrationNbr>
			<Trusteeship>0</Trusteeship>
			<CompanyID>0</CompanyID>
			<System5>0</System5>
			<NaturalPerson>
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				<INSS>42040610511</INSS>
				<WorkerRecord>
					<EmployerClass>048</EmployerClass>
					<WorkerCode>015</WorkerCode>
					<NOSSQuarterStartingDate>2021-01-01</NOSSQuarterStartingDate>
					<NOSSQuarterEndingDate>2020-03-31</NOSSQuarterEndingDate>
					<Border>0</Border>
					<Occupation>
						<OccupationSequenceNbr>01</OccupationSequenceNbr>
						<OccupationStartingDate>2003-06-15</OccupationStartingDate>
						<OccupationEndingDate>2021-03-31</OccupationEndingDate>
						<JointCommissionNbr>118</JointCommissionNbr>
						<WorkingDaysSystem>500</WorkingDaysSystem>
						<ContractType>1</ContractType>
						<RefMeanWorkingHours>1900</RefMeanWorkingHours>
						<MeanWorkingHours>3800</MeanWorkingHours>
						<ReorganisationMeasure>6</ReorganisationMeasure>
						<Retired>0</Retired>
						<SeverancePayment>
							<SeverancePaymentStartDate>2021-04-01</SeverancePaymentStartDate>
							<SeverancePaymentEndDate>2021-03-31</SeverancePaymentEndDate>
						</SeverancePayment>
						<Service>
							<ServiceSequenceNbr>01</ServiceSequenceNbr>
							<ServiceCode>01</ServiceCode>
							<ServiceNbrDays>6500</ServiceNbrDays>
							<ServiceNbrHours>24700</ServiceNbrHours>
						</Service>
						<Remun>
							<RemunSequenceNbr>01</RemunSequenceNbr>
							<RemunCode>01</RemunCode>
							<RemunAmount>238795</RemunAmount>
						</Remun>
						<RiskDetailOccupation>
							<LastWorkingDayDate>2021-03-31</LastWorkingDayDate>
							<CalculationBaseAllowance>
								<RemunerationTimeUnit>1</RemunerationTimeUnit>
								<PieceTaskServicesCommissionRemunerationBasisAmount>89900</PieceTaskServicesCommissionRemunerationBasisAmount>
								<StableOccupationIndicator>1</StableOccupationIndicator>
								<PartTimeCalculBase>
									<RemunerationTimeUnit>1</RemunerationTimeUnit>
									<PartTimeHourlyGrossSalary>96678</PartTimeHourlyGrossSalary>
								</PartTimeCalculBase>
								<ExceptSituationCalculBase>
									<ExceptSituationMeanWorkingHours>3800</ExceptSituationMeanWorkingHours>
								</ExceptSituationCalculBase>
							</CalculationBaseAllowance>
							<ReferencePeriod>
								<RefStartingDate>2021-05-06</RefStartingDate>
								<RefEndingDate>2020-11-16</RefEndingDate>
								<NatureOfDay>
									<DayIndicator>--05-06</DayIndicator>
									<DayNatureCode>2.4</DayNatureCode>
								</NatureOfDay>
								<NatureOfDay>
									<DayIndicator>--05-07</DayIndicator>
									<DayNatureCode>2.4</DayNatureCode>
								</NatureOfDay>
								<NatureOfDay>
									<DayIndicator>--05-08</DayIndicator>
									<DayNatureCode>2.4</DayNatureCode>
								</NatureOfDay>
								<NatureOfDay>
									<DayIndicator>--05-09</DayIndicator>
									<DayNatureCode>1</DayNatureCode>
								</NatureOfDay>
								<NatureOfDay>
									<DayIndicator>--05-10</DayIndicator>
									<DayNatureCode>2.5</DayNatureCode>
								</NatureOfDay>
								<NatureOfDay>
									<DayIndicator>--05-11</DayIndicator>
									<DayNatureCode>2.5</DayNatureCode>
								</NatureOfDay>
								<NatureOfDay>
									<DayIndicator>--05-12</DayIndicator>
									<DayNatureCode>2.4</DayNatureCode>
								</NatureOfDay>
								<NatureOfDay>
									<DayIndicator>--05-13</DayIndicator>
									<DayNatureCode>2.5</DayNatureCode>
								</NatureOfDay>
								<NatureOfDay>
									<DayIndicator>--05-14</DayIndicator>
									<DayNatureCode>2.5</DayNatureCode>
								</NatureOfDay>
								<NatureOfDay>
									<DayIndicator>--05-15</DayIndicator>
									<DayNatureCode>2.5</DayNatureCode>
								</NatureOfDay>
							</ReferencePeriod>
						</RiskDetailOccupation>
					</Occupation>
				</WorkerRecord>
			</NaturalPerson>
		</EmployerDeclaration>
	</Form>
</ZIMA001>