CPWR- Referral (CP-1)



The CPWR Employment Information Request Form is to be completed in its entirety by a representative of the DOL.  It is not considered complete until the certifying Point of Contact (POC) has signed and dated the form. 


Section 1 - Employee Information




Employee              Survivor

Last  Name                                                    First                                                   MI

Claim Type




File Number

Social Security Number (If Different from File No.)


Section 2 - District Office Point of Contact


District Office:                       Cleveland            Jacksonville            Denver        Seattle



Number of attached Employment Response Reports requiring action: _________



Comments or other relevant information for CPWR:


New Referral                                Supplemental Referral                    Amending Referral














DOL-POC NAME___________________________________ DATE______________