Formulaire

Accident at work Statement of agricultural workers (Form 12502*03)

Cerfa 12502*03 (100 ATA 12)

To be completed in 4 copies. The employer must send 3 copies, by registered letter with acknowledgement of receipt, to the MSA fund on which the employee who is the victim of the accident depends, within 48 hours after knowledge of the accident. It must keep the 4e copy for 5 years.

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Émetteur du formulaire administratif : Central Fund of Agricultural Social Mutual Society (MSA)

Verified 28 August 2017 - Directorate for Legal and Administrative Information (Prime Minister)