Statement of Changes in Beneficial Ownership (4)
21 March 2023 - 07:39AM
Edgar (US Regulatory)
FORM 4
☐ Check this
box if no longer subject to Section 16. Form 4 or Form 5
obligations may continue. See Instruction 1(b).
|
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL
OWNERSHIP OF SECURITIES
|
OMB
APPROVAL
OMB Number: 3235-0287
Estimated average burden
hours per response... 0.5 |
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Filed pursuant to Section 16(a) of the
Securities Exchange Act of 1934 or Section 30(h) of the Investment
Company Act of 1940
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|
1. Name
and Address of Reporting Person * Hagen Thomas B |
2. Issuer Name and Ticker or Trading
Symbol ERIE INDEMNITY CO [ ERIE ] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)__X__
Director _____
10% Owner
_____ Officer (give title
below) _____ Other
(specify below)
|
(Last)
(First)
(Middle)
230 WEST 6TH STREET |
3. Date of Earliest Transaction (MM/DD/YYYY)
3/17/2023
|
(Street)
ERIE, PA 16507-1319 |
4. If Amendment, Date Original Filed
(MM/DD/YYYY)
|
6. Individual or Joint/Group Filing
(Check Applicable Line) _X _ Form filed by One Reporting Person
___ Form filed by More than One Reporting Person |
(City)
(State)
(Zip)
|
Rule 10b5-1(c) Transaction Indication
☐ Check this box to indicate
that a transaction was made pursuant to a contract, instruction or
written plan that is intended to satisfy the affirmative defense
conditions of Rule 10b5-1(c). See Instruction 10. |
Table I - Non-Derivative Securities Acquired, Disposed of, or
Beneficially Owned
|
1.Title of Security
(Instr. 3) |
2. Trans. Date |
2A. Deemed Execution Date, if any |
3. Trans. Code
(Instr. 8) |
4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5) |
5. Amount of Securities Beneficially Owned Following
Reported Transaction(s)
(Instr. 3 and 4) |
6. Ownership Form: Direct (D) or Indirect (I)
(Instr. 4) |
7. Nature of Indirect Beneficial Ownership (Instr.
4) |
Code |
V |
Amount |
(A) or (D) |
Price |
Class A Common Stock |
|
|
|
|
|
|
|
5100 |
D |
|
Class A Common Stock |
|
|
|
|
|
|
|
12230 |
I |
Estate of Susan H. Hagen (1) |
Class A Common Stock |
|
|
|
|
|
|
|
10086059 |
I |
Family L.P. (2) |
Class A Common Stock |
|
|
|
|
|
|
|
6658800 |
I |
Susan Hagen Estate Settlement
Trust (1) |
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible
securities)
|
1. Title of Derivate Security
(Instr. 3) |
2. Conversion or Exercise Price of Derivative
Security |
3. Trans. Date |
3A. Deemed Execution Date, if any |
4. Trans. Code
(Instr. 8) |
5. Number of Derivative Securities Acquired (A) or
Disposed of (D)
(Instr. 3, 4 and 5) |
6. Date Exercisable and Expiration Date |
7. Title and Amount of Securities Underlying
Derivative Security
(Instr. 3 and 4) |
8. Price of Derivative Security
(Instr. 5) |
9. Number of derivative Securities Beneficially
Owned Following Reported Transaction(s) (Instr. 4) |
10. Ownership Form of Derivative Security: Direct
(D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr.
4) |
Code |
V |
(A) |
(D) |
Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
Class B Common Stock |
$0 (3) |
|
|
|
|
|
|
(3) |
(3) |
Class A Common Stock |
9600 |
|
4 |
D |
|
Class B Common Stock |
$0 (3) |
|
|
|
|
|
|
(3) |
(3) |
Class A Common Stock |
28800 |
|
12 |
I |
Susan Hagen Estate Settlement
Trust (1) |
Directors' Deferred Compensation Share
Credits |
$0 (4) |
|
|
|
|
|
|
(5) |
(5) |
Class A Common Stock |
12993.621 |
|
12993.621 |
D |
|
Class B Common Stock |
$0 (3) |
3/17/2023 |
|
P |
|
20 |
|
(3) |
(3) |
Class A Common Stock |
48000 |
$818206.68 |
173 |
I |
Family L.P. (2) |
Explanation of
Responses: |
(1) |
These shares were owned by
Erie Indemnity Company director and reporting person, Susan Hirt
Hagen who died 6/15/15. By operation of law, her 6,658,800 Class A
shares and 12 Class B shares held in a revocable trust passed to an
irrevocable trust of which this reporting person became co-trustee,
sharing voting and investment powers. The 12,230 Class A shares
from Mrs. Hagen's Directors' Deferred Compensation Plan account
were subsequently transferred by the Company to her estate for
which this reporting person is co-executor, sharing voting and
investment powers. The reporting person disclaims beneficial
ownership of these securities except to the extent of his pecuniary
interest therein, and the inclusion of these shares in this report
shall not be deemed an admission of beneficial ownership of all of
the reported shares for purposes of Section 16 or any other
purpose. |
(2) |
These shares are held by the
Hagen FLP of which the reporting person is a Limited Partner and
the General Partner with the sole powers of investment and voting.
The reporting person disclaims beneficial ownership of these
securities except to the extent of his pecuniary interest therein,
and the inclusion of these shares in this report shall not be
deemed an admission of beneficial ownership of all of the reported
shares for purposes of Section 16 or any other purpose. |
(3) |
Pursuant to the Articles of
Incorporation of the Company, as amended, shares of Class B Common
Stock (voting) of Erie Indemnity Company are convertible at any
time to shares of Class A Common Stock (non-voting) at a conversion
rate of 2,400 shares of Class A Stock for each share of Class B
Stock. There are no exercise or expiration dates associated with
this conversion feature and no specific exercise price when a Class
B share is converted into Class A shares. |
(4) |
Conversion price is not
applicable to shares granted under the Outside Directors' Deferred
Compensation Plan. |
(5) |
The shares subject to this
reporting are Share Credits which are periodically credited to the
accounts of certain Directors of Erie Indemnity Company pursuant to
its Outside Directors' Stock Plan. These Share Credits represent
the right to receive an equivalent number of shares of Erie
Indemnity Company Class A common stock when the reporting
individual's service as a Director of the Company ends. There are
no exercisable or expiration dates for these
securities. |
Reporting
Owners
|
Reporting Owner Name / Address |
Relationships
|
Director |
10% Owner |
Officer |
Other |
Hagen Thomas B
230 WEST 6TH STREET
ERIE, PA 16507-1319 |
X |
|
|
|
Signatures
|
Rebecca A. Buona, Power of
Attorney |
|
3/20/2023 |
**Signature of Reporting
Person |
Date |
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). |
** |
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. |
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. |
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