*Name of organization:

 

*Name of Director:

 

Web site address (eg: www.ErieInsurance.com):

*Are you a 501(c)(3) organization? 

*Contact Name:

 

*Contact Title:

 

Address:

*Street Address:

 

*City:

 

*State:

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*Zip:

  

*Phone Number:

   

Email Address: (eg: GivingNetwork@ErieInsurance.com)

*Year founded:

   

*Please describe the mission of your organization:

 

*Briefly describe the history of your organization:

 

*Number of employees:

   

*Number of volunteers:

   

*Who is served by your organization? Include the number of people served per year.

 

*Has Erie Insurance been involved with your organization in any way? If so, please explain the relationship. Identify any Erie Insurance Employees or Agents who serve as volunteers or Board members of your organization.

 

*Describe sponsorship or media opportunities for Erie Insurance.

 

*Project Name:

 

*Project Budget:	*Amount Requesting:
$	$
*Project Beginning Date:	*Project Ending Date:
/   /	/   /
*Date Funds are Needed:
/   /

*What is the purpose of this project? For which part(s) are you requesting funding?

 

*Who will benefit directly from this project? How many people?

 

*What are the measurable results of this project? Briefly describe your plan for evaluating its success.

 

The completed Budget Worksheet along with the completed Contribution Request form can either be e-mailed to Giving.Network@erieinsurance.com or mailed to Erie Insurance Giving Network at Erie Insurance Group, 100 Erie Insurance Place, Erie, PA 16530. All questions can be directed to (814) 870-7403 or (800) 458-0811 ext 7403.

*Name of organization:

Additional Information is required if requesting $10,000 or more

Please e-mail or mail your annual report to the Giving.Network@erieinsurance.com or to Erie Insurance Giving Network at Erie Insurance Group, 100 Erie Insurance Place, Erie, PA 16530.

*Describe your plans to sustain this project in the future.

 

*Please confirm your agreement to send a written report describing the results of the project activities including project evaluation measures to ERIE within 60 days of completion.

 

Diversity and Inclusion

At Erie Insurance we are strongly dedicated to the principle of "Equal Professional Service", which means that everyone we deal with is provided with the same high caliber service that is our hallmark. ERIE does not engage in illegal discrimination including discrimination on the basis of age, color, disability, military status, national origin, race, religion, sex, sexual orientation, socioeconomic status, or any illegal basis. We expect the organizations with which we partner or to whom we provide charitable funding to follow a similar philosophy of inclusion and nondiscrimination with the clients they serve.