-----BEGIN PRIVACY-ENHANCED MESSAGE----- Proc-Type: 2001,MIC-CLEAR Originator-Name: webmaster@www.sec.gov Originator-Key-Asymmetric: MFgwCgYEVQgBAQICAf8DSgAwRwJAW2sNKK9AVtBzYZmr6aGjlWyK3XmZv3dTINen TWSM7vrzLADbmYQaionwg5sDW3P6oaM5D3tdezXMm7z1T+B+twIDAQAB MIC-Info: RSA-MD5,RSA, T0I53cVQN01fHXVqS4ZiQfjpFpmR8XBRFJ9u+S0s2beYECdnGjC3YId4cCGKRK5W pQJjzxfwKhFHIVNHnIg+Ew== 0001177103-03-000071.txt : 20030422 0001177103-03-000071.hdr.sgml : 20030422 20030422120617 ACCESSION NUMBER: 0001177103-03-000071 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20030422 FILED AS OF DATE: 20030422 REPORTING-OWNER: COMPANY DATA: COMPANY CONFORMED NAME: BLACK SAMUEL P III CENTRAL INDEX KEY: 0001177252 RELATIONSHIP: DIRECTOR FILING VALUES: FORM TYPE: 4 BUSINESS ADDRESS: STREET 1: 400 FRENCH STREET STREET 2: SUITE 100 CITY: ERIE STATE: PA ZIP: 16507 BUSINESS PHONE: 8144536746 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: ERIE INDEMNITY CO CENTRAL INDEX KEY: 0000922621 STANDARD INDUSTRIAL CLASSIFICATION: INSURANCE AGENTS BROKERS & SERVICES [6411] IRS NUMBER: 250466020 STATE OF INCORPORATION: PA FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 000-24000 FILM NUMBER: 03657847 BUSINESS ADDRESS: STREET 1: 100 ERIE INSURANCE PL CITY: ERIE STATE: PA ZIP: 16530 BUSINESS PHONE: 8148702000 MAIL ADDRESS: STREET 1: 100 ERIE INSURANCE PLACE CITY: ERIE STATE: PA ZIP: 16530 4 1 bla128.htm SEC Form 4
FORM 4

[ ] Check this box if no longer
subject to Section 16. Form 4 or Form
5 obligations may continue.
See Instruction 1(b).

(Print or Type Responses)
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C.  20549

STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP

Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility
Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940
OMB APPROVAL



OMB Number: 3235-0287
Expires: January 31, 2005
Estimated average burden
hours per response. . . . . 0.5
1. Name and Address of Reporting Person*
Black, III, Samuel     P.

(Last)                      (First)                      (Middle)
121 East 2nd Street


(Street)
Erie, PA     16507-501

(City)                      (State)                      (Zip)

2. Issuer Name and Ticker or Trading Symbol

Erie Indemnity Company   ERIE
6. Relationship of Reporting Person(s) to Issuer
(Check all applicable)

           X          Director              X          10% Owner
                        Officer                             Other
                             

7. Individual or Joint/Group Filing (Check Applicable Line)

X   Form filed by One Reporting Person
      Form filed by More than One Reporting Person
3. I.R.S. Identification
    Number of Reporting
    Person, if an entity
    (voluntary)
4. Statement for
    Month/Day/Year

    April 22, 2003


5. If Amendment,
    Date of Original
    (Month/Day/Year)
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1. Title of Security
    (Instr. 3)

2. Transaction Date
    (Month/Day/Year)
2A. Deemed
      Execution
      Date, if any

      (Month/Day/Year)
3. Transaction
    Code
    and
    Voluntary
    Code
    (Instr. 8)



Code  |  V    
4. Securities Acquired (A) or Disposed (D) Of
    (Instr. 3, 4, and 5)





        Amount      |         A/D         |         Price          
5. Amount of
    Securities
    Beneficially
    Owned
    Following
    Reported
Transaction(s)

    (Instr. 3 and 4)
6. Owner-
    ship
    Form:
    Direct(D)
    or
    Indirect (I)

    (Instr. 4)
7. Nature of
     Indirect
     Beneficial
     Ownership

    (Instr. 4)
Class A Common Stock




129,750.0000
D

Class A Common Stock




5,709,240.0000
I
Black Interests Limited Partnership
Class A Common Stock




24,000.0000
I
Samuel P. Black & Associates, Inc.








Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
* If the form is filed by more than one reporting person, see Instruction 4(b)(v).

Persons who respond to the collection of information contained in this form are not required to
respond unless the form displays a currently valid OMB control number.
(over)
SEC 1474 (9-02)

Black, III, Samuel P. - April 22, 2003
Form 4 (continued)
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security
    (Instr. 3)
2. Conver-
    sion or
    Exercise
    Price of
    Deri-
    vative
    Security
3. Transaction
    Date

    (Month/
    Day/
    Year)
3A. Deemed
      Execution
      Date, if
      any

      (Month/
      Day/
      Year)
4. Transaction
    Code
    and
    Voluntary (V)
    Code
    (Instr.8)



Code | V    
5. Number of Derivative
    Securities Acquired (A)
    or Disposed (D) Of

    (Instr. 3,4 and 5)
6. Date Exercisable(DE) and
    Expiration Date(ED)
    (Month/Day/Year)






  (DE)     |     (ED)  
7. Title and Amount of
    Underlying Securities
    (Instr. 3 and 4)
8. Price
    of
    Derivative
    Security
    (Instr.5)
9. Number of
    Derivative
    Securities
    Beneficially
    Owned
    Following
    Reported
    Transactions
    (Instr.4)
10.
Owner-
ship
Form of
Deriv-
ative
Security:
Direct
(D)
or
Indirect
(I)
(Instr.4)
11. Nature of
      Indirect
      Beneficial
      Ownership
      (Instr.4)
Directors' Deferred Compensation Phantom Units
$0.0000 04/22/2003

J (1) |     
    (A) 2.8500
Class A Common Stock - 2.8500
432.9152
D

Class B Common Stock
Current market




Class A Common Stock - 24,000.0000
10.0000
D

Class B Common Stock
Current market




Class A Common Stock - 936,000.0000
390.0000
I
Black Interests Limited Partnership
Class B Common Stock
Current market




Class A Common Stock - 24,000.0000
10.0000
I
Estate of Samuel P. Black, Jr.












Explanation of Responses :


** Intentional misstatements or omissions of facts constitute Federal Criminal Violations.
        See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).

Note:   File three copies of this Form, one of which must be manually signed. If space is insufficient,
            see Instruction 6 for procedure.

Potential persons who are to respond to the collection of information contained in this form are not
required to respond unless the form displays a currently valid OMB number.
/s/ Samuel P. Black, III                   04-22-2003    
** Signature of Reporting Person                         Date




Page 2

Black, III, Samuel P. - April 22, 2003
Form 4 (continued)
FOOTNOTE Descriptions for Erie Indemnity Company ERIE

Form 4 - April 2003

Samuel P. Black, III
121 East 2nd Street

Erie, PA 16507-501

Explanation of responses:

(1)   Acquired under dividend reinvestment for Directors' Compensation Plan
Page 3
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