<?xml version='1.0' encoding='UTF-8'?>
<AADD001 xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:noNamespaceSchemaLocation="AADD001_20262.xsd">
	<Form>
		<Identification>AADD001</Identification>
		<FormCreationDate>2021-05-16</FormCreationDate>
		<FormCreationHour>08:55:13.084</FormCreationHour>
		<AttestationStatus>0</AttestationStatus>
		<TypeForm>RE</TypeForm>
		<Reference>
			<ReferenceType>5</ReferenceType>
			<ReferenceOrigin>3</ReferenceOrigin>
			<ReferenceNbr>Test Circuit CIN</ReferenceNbr>
		</Reference>
		<InsuredPersonId>
			<INSS>80000079512</INSS>
		</InsuredPersonId>
		<AskedDeclaration>
			<Identification>ZIMA001</Identification>
			<IdentificationOfRisk>001</IdentificationOfRisk>
			<ParticularSituationIndicator>0</ParticularSituationIndicator>
			<ReferencePeriod>
				<RefStartingDate>2021-05-06</RefStartingDate>
			</ReferencePeriod>
		</AskedDeclaration>
		<CoordinatesContactPerson>
			<Name>John</Name>
			<FirstName>Smith</FirstName>
			<Address>
				<Street>Teststraat</Street>
				<HouseNbr>20</HouseNbr>
				<ZIPCode>6000</ZIPCode>
				<City>Charleroi</City>
				<Country>150</Country>
			</Address>
			<Communication>
				<PhoneNbr>091111111</PhoneNbr>
				<EmailAddress>js@test.be</EmailAddress>
			</Communication>
		</CoordinatesContactPerson>
	</Form>
</AADD001>