<?xml version='1.0' encoding='UTF-8'?>
<AOAT004 xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:noNamespaceSchemaLocation="AOAT004_20261.xsd">
	<Form>
		<Identification>AOAT004</Identification>
		<FormCreationDate>2022-08-11</FormCreationDate>
		<FormCreationHour>09:17:58.082</FormCreationHour>
		<AttestationStatus>0</AttestationStatus>
		<TypeForm>SU</TypeForm>
		<DclInformation>
			<LanguageCodePdf>2</LanguageCodePdf>
		</DclInformation>
		<RiskIdentification>
			<IdentificationOfRisk>001</IdentificationOfRisk>
		</RiskIdentification>
		<EmployerDeclarationLink>
			<NOSSRegistrationNbr>141137377</NOSSRegistrationNbr>
			<Trusteeship>0</Trusteeship>
			<CompanyID>1111111111</CompanyID>
			<NaturalPerson>
				<NaturalPersonSequenceNbr>1</NaturalPersonSequenceNbr>
				<INSS>57040610511</INSS>
				<AccidentLink>
					<AccidentDate>2004-01-01</AccidentDate>
				</AccidentLink>
				<SeriousAccidentData>
					<AccidentNature>0</AccidentNature>
					<AccidentConsequences>2</AccidentConsequences>
					<LastEventCode>11</LastEventCode>
					<ObjectCode>02.02</ObjectCode>
					<InjuriesNatureCode>041</InjuriesNatureCode>
					<SeriousAccidentDescription>c'est un accident très garve qui s'est produit pendant le remplacement de pause</SeriousAccidentDescription>
					<VictimNbr>15</VictimNbr>
					<AccidentPlaceAddress>
						<AccidentPlaceStreet>rue haute</AccidentPlaceStreet>
						<AccidentPlaceHouseNbr>123</AccidentPlaceHouseNbr>
						<AccidentPlacePostBox>35</AccidentPlacePostBox>
						<AccidentPlaceZIPCode>5000</AccidentPlaceZIPCode>
						<AccidentPlaceCity>Namur</AccidentPlaceCity>
						<AccidentPlaceCountry>150</AccidentPlaceCountry>
					</AccidentPlaceAddress>
				</SeriousAccidentData>
			</NaturalPerson>
		</EmployerDeclarationLink>
	</Form>
</AOAT004>