<?xml version='1.0' encoding='UTF-8'?>
<AOAT504 xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:noNamespaceSchemaLocation="AOAT504_20261.xsd">
	<Form>
		<Identification>AOAT504</Identification>
		<FormCreationDate>2022-08-11</FormCreationDate>
		<FormCreationHour>09:20:58.082</FormCreationHour>
		<AttestationStatus>0</AttestationStatus>
		<TypeForm>SU</TypeForm>
		<HandledOriginalForm>
			<Identification>AOAT004</Identification>
			<FormCreationDate>2004-06-22</FormCreationDate>
			<FormCreationHour>12:24:22.539</FormCreationHour>
			<AttestationStatus>0</AttestationStatus>
			<TypeForm>SU</TypeForm>
		</HandledOriginalForm>
		<DclInformation>
			<LanguageCodePdf>2</LanguageCodePdf>
		</DclInformation>
		<RiskIdentification>
			<IdentificationOfRisk>001</IdentificationOfRisk>
		</RiskIdentification>
		<HandledReference>
			<ReferenceType>1</ReferenceType>
			<ReferenceOrigin>2</ReferenceOrigin>
			<ReferenceNbr>34000055CL00X</ReferenceNbr>
		</HandledReference>
		<Informant>
			<InformantUserId>drs test id</InformantUserId>
			<InformantName>drs name</InformantName>
			<InformantFirstName>drsfirstname</InformantFirstName>
		</Informant>
		<EmployerDeclarationLink>
			<NOSSRegistrationNbr>049328185</NOSSRegistrationNbr>
			<Trusteeship>0</Trusteeship>
			<CompanyID>0424753892</CompanyID>
			<HandledEmployerDeclarationLink>
				<NOSSRegistrationNbr>049328185</NOSSRegistrationNbr>
				<Trusteeship>0</Trusteeship>
				<CompanyID>424753892</CompanyID>
				<EmployerDenomination>LA MAISON DU TRAVAIL    INTERIMAIRE SPRL MTI    INTERIM SPRL</EmployerDenomination>
				<EmployerStreet>AV.HOUZEAU 91 A</EmployerStreet>
				<EmployerZIPCode>1180</EmployerZIPCode>
				<EmployerCity>UCCLE</EmployerCity>
				<EmployerCountry>150</EmployerCountry>
				<LegalForm>SPRL</LegalForm>
				<ImportanceCode>5</ImportanceCode>
			</HandledEmployerDeclarationLink>
			<NaturalPerson>
				<NaturalPersonSequenceNbr>1</NaturalPersonSequenceNbr>
				<INSS>77032011352</INSS>
				<HandledNaturalPerson>
					<NaturalPersonSequenceNbr>1</NaturalPersonSequenceNbr>
					<INSS>77032011352</INSS>
					<WorkerName>HOCQUET</WorkerName>
					<WorkerFirstName>JONATHAN CHRISTIAN</WorkerFirstName>
					<WorkerBirthdate>1977-03-20</WorkerBirthdate>
					<WorkerSex>1</WorkerSex>
					<Nationality>00150</Nationality>
					<OriolusSuccessCode>1</OriolusSuccessCode>
					<OriolusSubStatusRip>0</OriolusSubStatusRip>
					<BisFlagIndication>0</BisFlagIndication>
				</HandledNaturalPerson>
				<AccidentLink>
					<AccidentDate>2004-01-01</AccidentDate>
				</AccidentLink>
				<SeriousAccidentData>
					<AccidentNature>0</AccidentNature>
					<AccidentConsequences>2</AccidentConsequences>
					<LastEventCode>83</LastEventCode>
					<ObjectCode>01.02</ObjectCode>
					<InjuriesNatureCode>032</InjuriesNatureCode>
					<SeriousAccidentDescription>c'est un accident très garve qui s'est produit pendant le remplacement de pause</SeriousAccidentDescription>
					<VictimNbr>15</VictimNbr>
					<YardTicket>340008R0PE00M</YardTicket>
					<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>
</AOAT504>