-----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, BDSZxyLp5JphuykKW81mf4b1KRtXZBUftdXdEYj0jvFqIPmb2sX5PZIqYSFw40Hn D6FXppZ+luzGIkPti7Y89A== 0001177103-05-000076.txt : 20050308 0001177103-05-000076.hdr.sgml : 20050308 20050308122813 ACCESSION NUMBER: 0001177103-05-000076 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20050222 FILED AS OF DATE: 20050308 DATE AS OF CHANGE: 20050308 ISSUER: 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 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 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: BLACK SAMUEL P III CENTRAL INDEX KEY: 0001177252 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 000-24000 FILM NUMBER: 05666021 BUSINESS ADDRESS: STREET 1: 121 EAST 2ND ST CITY: ERIE STATE: PA ZIP: 16507 BUSINESS PHONE: 8144536746 MAIL ADDRESS: STREET 1: 121 EAST 2ND STREET CITY: ERIE STATE: PA ZIP: 16507 4 1 bla602.xml X0202 4 2005-02-22 0 0000922621 ERIE INDEMNITY CO ERIE 0001177252 BLACK SAMUEL P III 121 EAST 2ND STREET ERIE PA 165071501 0 0 1 0 Class A Common Stock 2005-02-22 4 J 0 125000 0 D 4750.0000 D Class A Common Stock 5709240.0000 I Black Interests Limited Partnership Class A Common Stock 24000.0000 I Samuel P. Black & Associates, Inc. Class B Common Stock 2005-02-24 5 W 0 10 0 A Class A Common Stock 24000.0000 20.0000 D Class B Common Stock 2005-02-24 5 W 0 10 0 D Class A Common Stock 24000.0000 0.0000 I Estate of Samuel P. Black, Jr. Class B Common Stock 0.0000 Class A Common Stock 936000.0000 390.0000 I Black Interests Limited Partnership Directors' Deferred Compensation Phantom Units 0.0000 Class A Common Stock 1561.7941 1561.7941 D Mr. Black unintentionally failed to timely file a Form 4 to report the transfer of shares to his former spouse pursuant to a marital settlement agreement. Market value at the date of conversion at the rate of 2,400 shares of Class A for each share of Class B. The shares subject to this reporting are phantom Share Credits which are periodically credited to the accounts of certain Directors of Erie Indemnity Company pursuant to its Outside Directors Stock Plan. These Credit Shares are actually paid to the reporting individual in shares of Erie Indemnity Company Class A Common Stock when their service as a Director of Erie Indemnity Company ends. There is no exercisable date for these securities. The shares subject to this reporting are phantom Share Credits which are periodically credited to the accounts of certain Directors of Erie Indemnity Company pursuant to its Outside Directors Stock Plan. These Credit Shares are actually paid to the reporting individual in shares of Erie Indemnity Company Class A Common Stock when their service as a Director of Erie Indemnity Company ends. There is no expiration date for these securities. Conversion price is not applicable to shares granted under the Outside Directors' Deferred Compensation Plan. By: Linda A. Etter, Power of Attorney 2005-03-07 -----END PRIVACY-ENHANCED MESSAGE-----