Employer

St. Luke'S Health Network, Inc.

801 Ostrum St, Bethlehem, PA 18015 · EIN 23-2384282 · Jan 1, 2025 to Dec 31, 2025

Plan year 2025

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Schedule A

Direct compensation

Coverage contracts on the filing. If the carrier did not provide Schedule A, the row is listed with that note.

Visible subtotal $940,998

Coverage	Carrier	Broker	Lives	Direct comp
Vision	Vision Service Plan	—	15714	Comp not disclosed Premium $2,858,264
Life	United Of Omaha Life Insurance Company	Fmlasource Inc.	20284	$176,474 17.5% of $1,005,570
Life	United Of Omaha Life Insurance Company	Bsi Corporate Benefits, Inc.	20284	$28,750 2.9% of $1,005,570
Other	United Of Omaha Life Insurance Company	Bsi Corporate Benefits, Inc.	17080	$28,750 0.7% of $4,296,712
Voluntary Short Term Disability	United Of Omaha Life Insurance Company	Bsi Corporate Benefits, Inc.	1967	$28,750 1.8% of $1,626,510
Voluntary Critical Illness	United Of Omaha Life Insurance Company	Bsi Corporate Benefits, Inc.	3082	$182,058 21.4% of $851,710
Voluntary Accident	United Of Omaha Life Insurance Company	Bsi Corporate Benefits, Inc.	7136	$196,750 21.1% of $933,333
Other	United Of Omaha Life Insurance Company	Bsi Corporate Benefits, Inc.	9855	$28,750 0.5% of $5,529,349
Other	United Of Omaha Life Insurance Company	Bsi Corporate Benefits, Inc.	1121	$28,750 4.1% of $701,581
Other	United Of Omaha Life Insurance Company	Bsi Corporate Benefits, Inc.	1216	$14,751 6.6% of $224,976
Voluntary Term Life	United Of Omaha Life Insurance Company	Bsi Corporate Benefits, Inc.	6899	$227,215 6.9% of $3,307,747

Schedule C

Plan-paid amounts to each named party on the filing, with the role they reported. This is not a carrier commission and is not added to Schedule A.

Visible subtotal $8,910,017

Party	Type	Amount	$ / Enrolled / Year
Bluecross Blueshield Of Sc	Admin	$8,191,874	$403.86
United Concordia Companies, Inc.	Admin	$718,143	$35.40

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