<?xml version='1.0' encoding='UTF-8'?>
<AOAT501 xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:noNamespaceSchemaLocation="AOAT501_20261.xsd">
	<Form>
		<Identification>AOAT501</Identification>
		<FormCreationDate>2022-08-11</FormCreationDate>
		<FormCreationHour>09:18:58.082</FormCreationHour>
		<AttestationStatus>0</AttestationStatus>
		<TypeForm>SU</TypeForm>
		<HandledOriginalForm>
			<Identification>AOAT001</Identification>
			<FormCreationDate>2003-09-17</FormCreationDate>
			<FormCreationHour>10:43:58.082</FormCreationHour>
			<AttestationStatus>0</AttestationStatus>
			<TypeForm>SU</TypeForm>
		</HandledOriginalForm>
		<DclInformation>
			<LanguageCodePdf>1</LanguageCodePdf>
		</DclInformation>
		<RiskIdentification>
			<IdentificationOfRisk>001</IdentificationOfRisk>
		</RiskIdentification>
		<HandledReference>
			<ReferenceType>1</ReferenceType>
			<ReferenceOrigin>2</ReferenceOrigin>
			<ReferenceNbr>3400000LSF01Q</ReferenceNbr>
		</HandledReference>
		<Informant>
			<InformantUserId>drsheirman</InformantUserId>
			<InformantName>Heirman</InformantName>
			<InformantFirstName>Willem</InformantFirstName>
		</Informant>
		<EmployerDeclarationLink>
			<NOSSRegistrationNbr>141137377</NOSSRegistrationNbr>
			<Trusteeship>0</Trusteeship>
			<CompanyID>1111111111</CompanyID>
			<HandledEmployerDeclarationLink>
				<NOSSRegistrationNbr>141137377</NOSSRegistrationNbr>
				<Trusteeship>0</Trusteeship>
				<CompanyID>1111111111</CompanyID>
				<EmployerDenomination>Algemene Bouwwerken</EmployerDenomination>
				<EmployerStreet>Kolonel Dussartplein</EmployerStreet>
				<EmployerHouseNbr>35</EmployerHouseNbr>
				<EmployerZIPCode>3500</EmployerZIPCode>
				<EmployerCity>Hasselt</EmployerCity>
				<ImportanceCode>4</ImportanceCode>
			</HandledEmployerDeclarationLink>
			<NaturalPerson>
				<NaturalPersonSequenceNbr>1</NaturalPersonSequenceNbr>
				<INSS>57040610511</INSS>
				<WorkerStreet>Kenislei</WorkerStreet>
				<WorkerHouseNbr>67</WorkerHouseNbr>
				<WorkerPostBox>B5</WorkerPostBox>
				<WorkerZIPCode>2930</WorkerZIPCode>
				<WorkerCity>Brasschaat</WorkerCity>
				<WorkerCountry>150</WorkerCountry>
				<HandledNaturalPerson>
					<NaturalPersonSequenceNbr>1</NaturalPersonSequenceNbr>
					<INSS>57040610511</INSS>
					<WorkerName>Dulière</WorkerName>
					<WorkerFirstName>Michel</WorkerFirstName>
					<WorkerBirthdate>1957-04-06</WorkerBirthdate>
					<WorkerSex>1</WorkerSex>
					<WorkerStreet>Kenislei</WorkerStreet>
					<WorkerHouseNbr>67</WorkerHouseNbr>
					<WorkerPostBox>B5</WorkerPostBox>
					<WorkerZIPCode>2930</WorkerZIPCode>
					<WorkerCity>Brasschaat</WorkerCity>
					<WorkerCountry>150</WorkerCountry>
					<Nationality>111</Nationality>
					<OriolusSuccessCode>1</OriolusSuccessCode>
					<OriolusSubStatusRip>0</OriolusSubStatusRip>
					<BisFlagIndication>0</BisFlagIndication>
					<PreviousINSS>57140610511</PreviousINSS>
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				<WorkerRecordLink>
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					<WorkerCode>015</WorkerCode>
					<HandledWorkerRecordLink>
						<EmployerClass>123</EmployerClass>
						<WorkerCode>015</WorkerCode>
						<ActivityCode>45230</ActivityCode>
					</HandledWorkerRecordLink>
					<OccupationLink>
						<OccupationStartingDate>1999-04-01</OccupationStartingDate>
						<OccupationEndingDate>2005-04-01</OccupationEndingDate>
						<JointCommissionNbr>124</JointCommissionNbr>
						<WorkingDaysSystem>500</WorkingDaysSystem>
						<MeanWorkingHours>3800</MeanWorkingHours>
						<RefMeanWorkingHours>3800</RefMeanWorkingHours>
						<Retired>0</Retired>
						<Apprenticeship>1</Apprenticeship>
						<ContractType>1</ContractType>
						<RemunMethod>1</RemunMethod>
						<HandledOccupationLink>
							<OccupationStartingDate>1999-04-01</OccupationStartingDate>
							<OccupationEndingDate>2005-04-01</OccupationEndingDate>
							<JointCommissionNbr>124</JointCommissionNbr>
							<WorkingDaysSystem>500</WorkingDaysSystem>
							<MeanWorkingHours>3800</MeanWorkingHours>
							<RefMeanWorkingHours>3800</RefMeanWorkingHours>
							<Retired>0</Retired>
							<ContractType>1</ContractType>
							<RemunMethod>1</RemunMethod>
							<InternalOccupationNbr>3400000L5G01Q</InternalOccupationNbr>
							<OccupationValidationCode>100</OccupationValidationCode>
						</HandledOccupationLink>
						<SupplementaryCalculationBaseAllowance>
							<EndYearBonusCode>4</EndYearBonusCode>
							<EndYearBonusAmount>102000</EndYearBonusAmount>
							<EndYearBonusValue>305</EndYearBonusValue>
							<EndYearBonusHours>2155</EndYearBonusHours>
							<Advantage>512564</Advantage>
							<AdvantageDescription>Diverse voordelen</AdvantageDescription>
						</SupplementaryCalculationBaseAllowance>
						<CalculationBaseAllowance>
							<RemunerationTimeUnit>3</RemunerationTimeUnit>
							<Cycle>52</Cycle>
							<RemunerationBasisAmount>35000</RemunerationBasisAmount>
						</CalculationBaseAllowance>
						<LostWorkingHours>
							<LooseWorkHoursNumber>5</LooseWorkHoursNumber>
							<SalaryLossOfLooseWorkHours>5268</SalaryLossOfLooseWorkHours>
						</LostWorkingHours>
						<FunctionChange>
							<HasChangedOfFunction>1</HasChangedOfFunction>
							<FunctionLastChange>2003-04-01</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>41</LastEventCode>
								<ObjectCode>14.01</ObjectCode>
								<AccidentCardYear>2003</AccidentCardYear>
								<AccidentCardSequenceNumber>4</AccidentCardSequenceNumber>
								<HandledAccident>
									<AccidentDate>2003-09-14</AccidentDate>
									<AccidentDay>7</AccidentDay>
								</HandledAccident>
								<EconomicConsequences>
									<AccidentConsequences>5</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>
									<DeceaseDate>2003-04-10</DeceaseDate>
									<InternalAdministerCare>1</InternalAdministerCare>
									<InternalAdministerDate>2003-09-14</InternalAdministerDate>
									<AdministerHour>1035</AdministerHour>
									<AdministerQuality>EHBO verantw.</AdministerQuality>
									<InterventionDescription>Eerste zorgen toegediend</InterventionDescription>
									<ExternalAdministerCare>1</ExternalAdministerCare>
									<ExternalDoctorInterventionDate>2003-09-14</ExternalDoctorInterventionDate>
									<ExternalDoctorInterventionHour>1045</ExternalDoctorInterventionHour>
									<HospitalAdministerCare>1</HospitalAdministerCare>
									<HospitalInterventionDate>2003-09-14</HospitalInterventionDate>
									<HospitalInterventionHour>1100</HospitalInterventionHour>
									<Doctor>
										<ExternalDoctorId>12345678912</ExternalDoctorId>
										<HandledDoctor>
											<ExternalDoctorId>12345678912</ExternalDoctorId>
											<ExternalDoctorInterventionDate>2003-09-14</ExternalDoctorInterventionDate>
											<DoctorLookupResultCode>1</DoctorLookupResultCode>
											<ExternalDoctorMostRecentId>12345620045</ExternalDoctorMostRecentId>
											<ExternalDoctorName>Jacobs</ExternalDoctorName>
											<ExternalDoctorFirstName>François</ExternalDoctorFirstName>
											<HandledAddress>
												<Street>Haagdoornlaan</Street>
												<HouseNbr>27</HouseNbr>
												<PostBox>B21A</PostBox>
												<ZIPCode>2950</ZIPCode>
												<City>Kapellen</City>
												<Country>150</Country>
												<HandledAddressDescription>
													<TypeOfAddress>3</TypeOfAddress>
												</HandledAddressDescription>
											</HandledAddress>
										</HandledDoctor>
									</Doctor>
									<Hospital>
										<HospitalId>71345678</HospitalId>
										<HospitalName>H. Hartziekenhuis</HospitalName>
										<Address>
											<Street>Bloklaan</Street>
											<HouseNbr>20</HouseNbr>
											<ZIPCode>1730</ZIPCode>
											<City>Asse</City>
											<Country>150</Country>
											<AddressDescription>
												<TypeOfAddress>4</TypeOfAddress>
											</AddressDescription>
										</Address>
									</Hospital>
								</MedicalConsequences>
								<Classification>
									<InternalRiskCode>785AB</InternalRiskCode>
								</Classification>
								<Classification>
									<InternalRiskCode>12</InternalRiskCode>
								</Classification>
								<Classification>
									<InternalRiskCode>986</InternalRiskCode>
								</Classification>
								<Classification>
									<InternalRiskCode>AA34</InternalRiskCode>
								</Classification>
								<Classification>
									<InternalRiskCode>9</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>0</EmployerRelatednessDegree>
								<VictimAccountNumber>BE539007547034</VictimAccountNumber>
								<AccountNbrFormat>1</AccountNbrFormat>
								<VictimPhoneNumber>036518220</VictimPhoneNumber>
								<Address>
									<Street>Leopoldlaan</Street>
									<HouseNbr>20</HouseNbr>
									<ZIPCode>9300</ZIPCode>
									<City>Aalst</City>
									<Country>150</Country>
									<AddressDescription>
										<TypeOfAddress>1</TypeOfAddress>
									</AddressDescription>
								</Address>
								<Mutuality>
									<MutualityCode>235</MutualityCode>
									<MutualityName>Vlaams Neutraal Ziekenfonds</MutualityName>
									<MutualityAffiliationId>123456789</MutualityAffiliationId>
									<Address>
										<Street>Statieplein</Street>
										<HouseNbr>12</HouseNbr>
										<ZIPCode>9300</ZIPCode>
										<City>Aalst</City>
										<Country>150</Country>
										<AddressDescription>
											<TypeOfAddress>4</TypeOfAddress>
										</AddressDescription>
									</Address>
								</Mutuality>
								<Work>
									<VictimWorkingAtOtherEmployer>0</VictimWorkingAtOtherEmployer>
									<ServiceEndingDateKnown>1</ServiceEndingDateKnown>
									<ServiceEndingDate>2005-04-01</ServiceEndingDate>
									<TempWorker>1</TempWorker>
									<DimonaNbr>0101</DimonaNbr>
									<FunctionCode>712</FunctionCode>
									<NormalJob>Metser</NormalJob>
									<ContractDurationCode>1</ContractDurationCode>
									<HandledWork>
										<DimonaNbr>0101</DimonaNbr>
										<DimonaNumberLookupResultCode>0</DimonaNumberLookupResultCode>
										<ServiceEntryDate>1999-04-01</ServiceEntryDate>
									</HandledWork>
									<UsingEmployer>
										<UsingEmployerCompanyID>1111111111</UsingEmployerCompanyID>
										<HandledUsingEmployer>
											<UsingEmployerCompanyID>1111111111</UsingEmployerCompanyID>
											<CompanyIDLookupResultCode>1</CompanyIDLookupResultCode>
											<UsingEmployerName>Moving Air</UsingEmployerName>
											<HandledAddress>
												<Street>Louis Paul Boon straat</Street>
												<ZIPCode>1000</ZIPCode>
												<City>Brussel</City>
												<Country>150</Country>
												<HandledAddressDescription>
													<TypeOfAddress>5</TypeOfAddress>
												</HandledAddressDescription>
											</HandledAddress>
										</HandledUsingEmployer>
									</UsingEmployer>
								</Work>
								<HandledVictim>
									<VictimAccountNumber>BE68539007547034</VictimAccountNumber>
								</HandledVictim>
							</Victim>
							<Employer>
								<AccountNumber>BE88091011476341</AccountNumber>
								<AccountNbrFormat>2</AccountNbrFormat>
								<BankIdentifierCode>BBRUBEBB</BankIdentifierCode>
								<ContactPhoneNumber>02-111111</ContactPhoneNumber>
								<PreventionMeasure>
									<PreventionMeasureDescription>afstand respecteren</PreventionMeasureDescription>
									<PreventionMeasureCode>24</PreventionMeasureCode>
								</PreventionMeasure>
								<HandledEmployer>
									<AccountNumber>BE88091011476341</AccountNumber>
								</HandledEmployer>
							</Employer>
							<Insurance>
								<InsurerId>1018</InsurerId>
								<PolicyIdentifier>123456789</PolicyIdentifier>
								<SubdivisionUsage>1</SubdivisionUsage>
								<SubdivisionNumber>31</SubdivisionNumber>
								<VictimTariffCode>55555</VictimTariffCode>
							</Insurance>
							<Presence>
								<VerbalLawsuitEstablished>1</VerbalLawsuitEstablished>
								<Witnesses>1</Witnesses>
								<ThirdResponsables>1</ThirdResponsables>
								<VerbalLawsuit>
									<VerbalLawsuitPlace>Particuliere woning</VerbalLawsuitPlace>
									<VerbalLawsuitAuthority>Federale politie</VerbalLawsuitAuthority>
									<VerbalLawsuitDate>2003-09-14</VerbalLawsuitDate>
									<VerbalLawsuitId>123456</VerbalLawsuitId>
								</VerbalLawsuit>
								<Witness>
									<TypeOfWitness>0</TypeOfWitness>
									<CoordinatesWitness>
										<WitnessName>Brogno</WitnessName>
										<WitnessFirstName>Dante</WitnessFirstName>
										<Address>
											<Street>Rue Paul Pastur</Street>
											<HouseNbr>20</HouseNbr>
											<ZIPCode>6000</ZIPCode>
											<City>Charleroi</City>
											<Country>150</Country>
											<AddressDescription>
												<TypeOfAddress>2</TypeOfAddress>
											</AddressDescription>
										</Address>
									</CoordinatesWitness>
								</Witness>
								<Witness>
									<TypeOfWitness>1</TypeOfWitness>
									<CoordinatesWitness>
										<WitnessName>De Cock</WitnessName>
										<WitnessFirstName>Jorn</WitnessFirstName>
										<Address>
											<Street>Haagdoornlaan</Street>
											<HouseNbr>27</HouseNbr>
											<ZIPCode>2950</ZIPCode>
											<City>Kapellen</City>
											<Country>150</Country>
											<AddressDescription>
												<TypeOfAddress>2</TypeOfAddress>
											</AddressDescription>
										</Address>
									</CoordinatesWitness>
								</Witness>
								<Witness>
									<TypeOfWitness>0</TypeOfWitness>
									<CoordinatesWitness>
										<WitnessName>Di Biaggio</WitnessName>
										<WitnessFirstName>Giuseppe</WitnessFirstName>
										<Address>
											<Street>Crutzenstraat</Street>
											<HouseNbr>34</HouseNbr>
											<PostBox>b4</PostBox>
											<ZIPCode>3500</ZIPCode>
											<City>Hasselt</City>
											<Country>150</Country>
											<AddressDescription>
												<TypeOfAddress>2</TypeOfAddress>
											</AddressDescription>
										</Address>
									</CoordinatesWitness>
								</Witness>
								<ThirdResponsable>
									<ThirdResponsableKnown>1</ThirdResponsableKnown>
									<CoordinatesThirdResponsable>
										<ThirdResponsableName>De Wolf</ThirdResponsableName>
										<ThirdResponsableFirstName>Koenraad</ThirdResponsableFirstName>
										<Address>
											<Street>Tertioweg</Street>
											<HouseNbr>20</HouseNbr>
											<ZIPCode>2000</ZIPCode>
											<City>Antwerpen</City>
											<Country>150</Country>
											<AddressDescription>
												<TypeOfAddress>2</TypeOfAddress>
											</AddressDescription>
										</Address>
									</CoordinatesThirdResponsable>
									<InsuranceThirdResponsable>
										<ThirdResponsablePolicyIdentifier>12345888B</ThirdResponsablePolicyIdentifier>
										<ThirdResponsableInsurerName>Collectieve Verzekeringen</ThirdResponsableInsurerName>
										<Address>
											<Street>St.-Jacobskruislaan</Street>
											<HouseNbr>20</HouseNbr>
											<ZIPCode>1050</ZIPCode>
											<City>Brussel</City>
											<Country>150</Country>
											<AddressDescription>
												<TypeOfAddress>4</TypeOfAddress>
											</AddressDescription>
										</Address>
									</InsuranceThirdResponsable>
								</ThirdResponsable>
							</Presence>
						</IndustrialAccidentDescription>
					</OccupationLink>
				</WorkerRecordLink>
			</NaturalPerson>
		</EmployerDeclarationLink>
	</Form>
</AOAT501>