International Risk UnderwritingForeign Travel and Residence Risks, Facts and Trends

Melissa Gallegos, FALU, FLMI, ACS, ARADirector, Team Manager

Brittany Donohue, FALU, ACS, ALMIUnderwriting Consultant

September 11, 2019

2

“The world is a book and those who do not travel read only one page.”

St. Augustine

3

Historical Growth of World Travel

Source: UNWTO

1950: 25 million 2005: 808 million 2016: 1.2 billion

Annual growth: 4% Forecast for 2030: 1.8 billion

4

Foreign risks are sensationalized in the news & entertainment media

Most short-term foreign travel is low risk

Foreign residence is far more significant than short-term foreign travel

Major mortality and morbidity differences exist among countries

Look beyond popular opinion and preconceptions

Foreign Residence and Travel Observations

http://affiliates.allposters.com/link/redirect.asp?item=357996&AID=1586801019&PSTID=1&LTID=2&lang=1http://affiliates.allposters.com/link/redirect.asp?item=357996&AID=1586801019&PSTID=1&LTID=2&lang=1

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How dangerous or safe is foreign travel?

What are the most significant mortality risks?

What are the major differences among nations?

Why does it matter what country you live in?

6Source: CIA World Fact book 2019 est.45 – USA: 80.10 years

Life Expectancy at Birth

High Years Low Years

Monaco 89.40 Afghanistan 52.10

Japan 85.50 Zambia 53.00

Singapore 85.50 Lesotho 53.00

Macau 84.60 Somalia 53.20

San Marino 83.40 Central African R. 53.30

Iceland 83.10 Mozambique 54.10

Hong Kong 83.10 Uganda 56.30

Andorra 82.90 Niger 56.30

Switzerland 82.70 Eswatini 57.20

Guernsey 82.70 Chad 57.50

Israel 82.70 Congo 58.10

Malta 82.70 Sierra Leone 59.00

South Korea 82.50 Nigeria 59.30

Italy 82.40 Cameroon 59.40

Australia 82.40 Cote D’Ivoire 60.10

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From Wikipedia, the free encyclopedia

Life_Expectancy_2013_Estimates_CIA_World_Factbook

Geography of Life Expectancy

Life Expectancy at Birth (Years)

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HIV/AIDS Adult Prevalence Rate

Source: CIA World Fact book 2017 est.

Country Percent Country Percent

Eswatini 27.40 Brazil 0.60

Lesotho 23.80 Spain 0.40

Botswana 22.80 United Kingdom 0.33

South Africa 18.80 Mexico 0.30

Zimbabwe 13.30 Germany 0.20

Namibia 12.10 Australia 0.10

Zambia 11.50 Iran 0.10

Malawi 9.60 Philippines 0.10

Equatorial Guinea 6.50 Somalia 0.10

United States – 0.30 %

9UNAIDS

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Tuberculosis (TB) Prevalence

Source: The World Bank 2017

(Selected Countries - cases per 100,000 population)

Countries TB Prevalence Countries TB Prevalence

Lesotho 665 Guyana 86

South Africa 567 China 63

Philippines 554 Mexico 22

Mozambique 551 Japan 15

Gabon 529 United Kingdom 9

Pakistan 267 Australia 7

India 204 Italy 7

Thailand 156 Canada 6

Vietnam 129 United States 3

11

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Hepatitis B Prevalence (percent of population)

Source: https://www.rightdiagnosis.com/h/hepatitis_b/stats-country.htm 8/13/2015 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4641116/

CountryHepatitis B

PrevalenceCountry

Hepatitis B

Prevalence

Zimbabwe 25.0 Saudi Arabia 1.5-2.6

Mali 15.5 Jordan 1.4

Nigeria 13.6 Iraq 0.6

Cameroon 10.1 USA 0.5

China 7.2

Zambia 6.5

South Korea 4.0

Bulgaria 3.8

India 3.7

Singapore 3.6

https://www.rightdiagnosis.com/h/hepatitis_b/stats-country.htm 8/13/2015

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Hepatitis B Prevalence

Source: WHO, work conducted by the London School of Hygiene & Tropical Medicine (LSHTM). See Annex 2.

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Hepatitis C Prevalence (selected countries percent of population)

Source: 1999 WHO

CountryHepatitis C

PrevalenceCountry

Hepatitis C

Prevalence

Egypt 18.1 India 1.8

Rwanda 17 United States 1.8

Bolivia 11.2 South Korea 1.7

Mongolia 10.7 Mexico 0.7

Vietnam 6.1 Australia 0.3

Thailand 5.6 Canada 0.1

China 3.0 United Kingdom 0.02

Japan 2.3 Sweden 0.003

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Maternal Mortality Rate (number of maternal deaths per 100,000 live births)

Source: CIA World Fact book 2016

Infant Mortality Rate (deaths before age one per 1,000 live births)

USA 5.80 (57th)

Country Deaths Country Deaths

Finland 3.0 Sierra Leone 1360

Greece 3.0 Central African R. 882

Iceland 3.0 Chad 856

Poland 3.0 Nigeria 814

Austria 4.0 South Sudan 789

Belarus 4.0 Somalia 732

Czechia 4.0 Liberia 725

Australia 6.0 Canada 7.0 USA 14.0

Country Deaths Country Deaths

Monaco 1.80 Afghanistan 112.80

Japan 2.00 Mali 100.00

Iceland 2.10 Somalia 96.60

Singapore 2.40 Central African R. 72.7

Source: CIA World Fact book 2015 est.

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Infectious and Parasitic Disease Mortality

Country Death rate per 100,000

population

Total Fatalities in 2008

Australia 10.0 2,100

United Kingdom 13.4 8,200

Germany 15.9 13,100

United States 22.8 71,200

Canada 37.0 12,300

India 181.9 2,149,100

Haiti 299.7 29,600

Nigeria 568.7 860,000

Dem Rep Congo 687.4 441,700

Malawi 744.4 106,800

Source: WHO 2008

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Global Smoking Prevalence

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Global Obesity Prevalence

In the U.S., obesity levels continue to rise, with 42% of Americans predicted to be obese

by 2030

Source: CDC

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WHO World Health Systems’ Ranking

Rank Country Rank Country

1 France 17 Netherlands

2 Italy 18 United Kingdom

6 Singapore 19 Ireland

7 Spain 20 Switzerland

9 Austria 25 Germany

10 Japan 27 United Arab Emirates

11 Norway 30 Canada

12 Portugal 32 Australia

14 Greece 36 Costa Rica

17 Netherlands 37 USA

High correlation between this rank and life expectancy rank.

USA: Physician density/1,000 pop. = (2.4), rank 49 Hospital beds/10,000 pop. = (30), rank 64

20

The availability of physician care is an indicator of the quality of a country’s healthcare system. The number of physicians per 1,000 population was provided by the World Economic Forum (WEF) as part of the Travel and Tourism competitive index. The most recent year of data available is as of 2017.

Physician Density

Physicians/1,000 population:

Top 5 countries

Physicians/1,000 population: Bottom 5

countries

1 Qatar 7.7 131 Tanzania 0.03

2 Spain 4.90 132 Burundi 0.03

3 Greece 4.40 133 Ethiopia 0.03

4 Russia 4.30 134 Sierra Leone 0.02

5 Norway 4.30 135 Malawi 0.01

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Physician Density

The United States has a physician density of 2.45 per 1,000 population and ranks 49 of the 135

countries provided by the WEF data in our study.

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Annual Global Deaths

Causes of Death Per Year

HIV/AIDS 1,100,000

Tuberculosis 1,800,000

Malaria 429,000

Motor vehicle accidents 1,250,000

Job related accident/illness 2,300,000

Armed conflicts 180,000

Terrorism* 28,238

Sources: WHO 2013-15, ILO 2014, IISS Armed Conflict Survey of 2015

*Includes perpetrators

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Deaths of U.S. Citizens Abroad by Non-natural Causes

Reported to U.S. State Department abroad Jan. 1, 2014, to Dec. 31,2014

810 total deaths reported (approx. 67,000,000 U.S. citizens traveled/resided abroad in 2014)

Main Non-natural Causes Number of Deaths Abroad Percent of Total

Motor vehicle accidents 225 27.8

Homicides 174 21.5

Suicide 140 17.3

Drowning 106 13.1

Other accidents 94 11.6

Drug related 27 3.3

Air accidents 19 2.3

Terrorism 19 2.3

Maritime accidents 6 0.8

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Causes of Non-natural Deaths Abroad of U.S. Citizens in 2014

Motor vehicle accidents28%

Homicides22%

Suicide17%

Drowning13%

Other accidents12%

Drug related3%

Air accidents2%

Terrorism2%

Maritime accidents1%

Total 810 deaths

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Deaths of U.S. Citizens Abroad by Non-natural Causes

Source: US Department of Commerce, National Travel and Tourism Office, July 2015

Most Common Causes of Death(October 2002-June 2015)

Cause of Death

Reported # of American

Deaths Abroad

Traffic Accidents 3,104

Homicide 2,000

Suicide 1,461

Drowning 1,320

Other Accidents 1,294

Countries with the Most American Deaths 2014-2015

Country

American Deaths

July 2014-June

2015

American

Visitors in 2014

Mexico 228 25,900,000

Thailand 35 339,000

Costa Rica 31 862,000

Philippines 29 708,000

Dominican

Republic

28 2,700,000

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U.S. Citizen Non-natural Deaths Abroad

Non-natural

Causes of DeathDeaths in Mexico Deaths in Canada

July 2007 – June 2011 Jan. – Dec. 2016 July 2007 – June 2011 Jan. – Dec. 2016

Vehicle Accidents 352 78 18 3

Homicides 313 73 1 1

Drownings 117 38 11 3

Other Accidents 80 31 5 1

Suicides 75 35 11 1

Other 30 3 3 0

Drug-related 10 5 2 1

Total 977 263 51 10

Mexico vs. Canada

Source: U.S. State Department

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U.S. Citizen Non-natural Deaths Abroad

Country # of Homicides

July 2007-

June 2011

Jan.-Dec.

2016

Mexico 313 73

Honduras 40 6

Philippines 39 8

Dominican

Rep

27 4

Guatemala 24 3

Haiti 20 6

Colombia 19 2

Costa Rica 16 3

El Salvador 16 2

Iraq 15 0

Jamaica 12 8

Source: U.S. State Department

Vehicle AccidentsJuly 2007-

June 2011

Jan.-Dec.

2016

Mexico 352 78

India 32 5

Dominican Rep 32 6

Thailand 31 11

SuicidesJuly 2007-

June 2011

Jan.-Dec.

2016

Mexico 75 35

Thailand 34 11

Germany 34 7

South Korea 30 6

DrowningsJuly 2007-

June 2011

Jan.-Dec.

2016

Mexico 117 38

Costa Rica 34 13

Bahamas 27 9

Dominican Rep 18 5

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Natural Causes

62%

Accidents

25%

Murder

7.8%

Suicide

5.2%

Major Causes of Traveler Deaths Abroad

Source: MacPherson, J. Travel Med, 2000

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Major Causes of Traveler Deaths Abroad

1 Hargarten SW, Baker TD, Guptill K. June 1991. Medical

College of Wisconsin, Milwaukee 2 MacPherson, J. Travel Med, 2000

U.S. Citizens1

Cardiovascular and cerebrovascular (mainly myocardial infarction

and stroke/CVA) 49%

Injuries/trauma (mainly traffic accidents) 25%

Canadian Citizens2

Natural deaths 62%

Accidental 24.99%

Murder 7.80%

Suicide 5.20%

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International Homicide Rates (per 100,000 population)

Country Murder Rates Country Murder Rates

Honduras 74.6 Andorra 0.0

El Salvador 64.2 Greece 0.1

Venezuela 62.0 Cyprus 0.1

Jamaica 36.1 Luxembourg 0.2

Belize 34.4 Japan 0.3

South Africa 33.0 Singapore 0.3

Guatemala 31.2 Switzerland 0.5

Colombia 27.9 Austria 0.5

Trinidad & Tobago 25.9 Indonesia 0.5

Brazil 24.6 Norway 0.6

Puerto Rico 18.5 Slovenia 0.7

Dominican Rep. 17.4 Poland 0.7

Mexico 15.7 Spain 0.7

Source: The World Bank 2014

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USA: 3.9

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Homicide Rates (per 100,000 population)

Two neighboring cities in 2016

Ciudad Juarez, Mexico: 43.63 El Paso, Texas: 2.77

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Country Guns per 100

people

Total firearm-related deaths per 100,000

population

Japan 0.6 0.06

Australia 15.0 1.04

Canada 30.8 2.44

Netherlands 3.9 0.46

Belgium 17.2 2.43

Sweden 31.6 1.47

Finland 45.3 3.64

Italy 11.9 1.28

Switzerland 45.7 3.84

United Kingdom 6.2 0.25

United States 88.8 10.20

Sources: The American Journal of Medicine, “Gun Ownership

and Firearm-related Deaths,” October 2013.

U.S. National Vital Statistics: 33,594 total firearm deaths in

USA in 2014.

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Occupational Accident Fatality Rate (per 100,000 workers)

Country Rate Country Rate

United Kingdom 0.8 Vietnam 27.0

Netherlands 1.5 Bangladesh 26.4

France 3.0 Egypt 24.0

Australia 3.2 Philippines 20.0

Japan 3.2 South Africa 19.2

Germany 3.6 Malaysia 18.3

United States 5.2 Mexico 15.9

Canada 6.4 U.A.E. 15.9

Italy 6.9 India 11.5

Poland 10.0 China 10.5

Source: Global Estimates of Accidents. Tampere University of Technology (Finland) 2005

2015: USA 3.4

4,836 total fatalities:

93% male, 7% female

Hours worked: male

57%, female 43% Source: U.S. Bureau of Labor Statistics 2015

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Worldwide, there are 2.3 million annual job-related deaths.

Work accidents are more prevalent in developing countries with dangerous construction, farming, mining, factory jobs and low safety standards

Developing countries’ occupational ill health risks are 10-20 times greaterthan those of developed countries

There were an estimated 58,200 workplace fatalities in China in 2013

Occupational Mortality

Source: International Labour Organization, 2014

and The Rand Corporation, 2016

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GDP per capita on a purchasing power parity basis was found in the CIA’s World Factbook and is an indicator of a country’s wealth, as well as the standard of living of its citizens.

Economic Factors – GDP per Capita

GDP – Top 5 countries GDP – Bottom 5 countries

Qatar $129,700 Somalia $400

Monaco $115,700 Central African Rep $700

Luxembourg $102,000 Burundi $800

Macau $96,100 Congo, D.R. $800

Singapore $87,100 Liberia $900

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Economic Factors – GDP per Capita

The per capita GDP in the U.S.A. is $57,300, which is a

rank of 20 of the 203 countries.

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The data for the Gini index as of 2013 is included in the CIA’s World Factbook. “The Gini index measures the degree of inequality in the distribution of family income in a country.” The index ranges from 0 to 100, with 0 indicating perfect income equality among households in a country and 100 is perfect inequality. Therefore, the higher the Gini index, the more income disparity there is within a country.

Gini Index – Income Distribution Inequality

Gini Index – top 5 countries Gini Index– bottom 5 countries

1 Slovenia 23.7 141 C. African Rep. 61.3

2 Ukraine 24.6 142 South Africa 62.9

3 Denmark 24.8 143 Sierra Leone 63.0

4 Sweden 24.9 144 Botswana 62.5

5 Czech Republic 24.9 145 Lesotho 63.2

The Gini index is 45 for U.S.A which ranks 102 out of the 145 countries with data, meaning there is a greater

difference in income distribution in the U.S. than in the majority of countries in this study

US CEO compensation ratio (S&P 500 companies) compared to rank & file worker:

1950s 20:1 1980 42:1 2013 204:1

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In US from 1979-2007 Top fifth in household income increased share of income by 10% (most going to top 1%), while 80% of households saw their share of income decline 2-3%. US income inequality has been steadily growing. Sources: Congressional Budget Office & Bloomberg

Generally, the Gini index is lowest in the Scandinavian countries in Europe and highest in South America and Africa.

Gini Index – Income Distribution Inequality

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Age of Death (Poor vs. Wealthy Countries)

Source: WHO, 2014

High-Income Countries

(Deaths among people age)

70% >70 yrs

29% 15-69

1% 0-14

Low-Income Countries

(Deaths among people

age)

20% >70 yrs

40% 15-69

40% 0-14

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Other Foreign Risk Factors

Mongolia has fewer than 2 people per square kilometer.

Population density of Lagos, Nigeria, is 10,000-50,000 per square

kilometer.

Population density

Access to medical care

Environment, climate, drought, famine

Legal issues

Natural disaster frequency and severity

Military conflict

Political situation – instability (Bolivia: 193 coups since 1825); foreign relations

Corruption (CPI: least – New Zealand and Denmark; most – Afghanistan and Somalia)

Document and claims fraud

Transparency International Corruption Perception Index 2016

42

Access to medications (prescription, nonprescription and non-FDA approved)

Availability of reliable medical records

Quality of medical care, access to new treatments, safety of blood supply

Socioeconomic conditions, hygiene, sanitation

Anti-selection potential

Other Foreign Risk Factors (cont’d.)

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Compounding Foreign Travel Risk

Serious pre-existing

medical conditions

Older age

Hazardous avocations and

lifestyle concerns

Long-distance travel (“economy

class syndrome”): approx. 3x

increased risk of venous

thrombosis on flights >4 hrs.

44

Tourist Injuries in European Union (EU)

Approximately 300,000,000 tourists visit EU countries annually

Approximately 3,800 tourists die of injuries annually while visiting the EU

30% of all tourist fatalities are due to injuries

Tourist vs. resident overall injury mortality is 1.70/1,000 vs. 0.37/1,000, representing a 4.6 times greater injury mortality rate for tourists

Injury fatalities peaked in 25- to 44-year-olds and were predominantly among males

Main causes: traffic accidents (2,900), drowning (340) and mountain activities (280)

Source: Bauer R, Kormer C, Sector M; Int J of Injury Control and Safety Promotion, March 2005.

45

Thirty years ago, Beijing had few cars. By 2007 it had 3 million cars. 2011, 5 million. Recently has begun banning on high pollution days.

Rapidly growing economies in the Middle East and Southeast Asia have a growing middle class with resulting increase in airborne particulates due to increased public transportation and personal vehicle use, with many thousands of deaths attributed to air pollution.

In 2009 China passed the USA to become the world’s largest new car market and remains #1 as of 2016.

Estimated: >700 fatalities and 45,000 injuries on China’s roads daily, >260,000 fatalities/yr.

Foreign Travel and Residence Risk: Changing World Traffic

Beijing, 1979 Beijing today

Source: WHO

45

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Road Traffic Mortality (annual number of deaths per 100,000 population)

Country

Road Traffic

Mortality Country

Road Traffic

Mortality

Thailand 36.2 India 16.6

Iran 32.1 Mexico 12.3

Rwanda 32.1 United States 10.6

Dominican Rep 29.3 Canada 6.8

Kenya 29.1 Belgium 6.7

Saudi Arabia 27.4 Italy 6.1

South Africa 25.1 Australia 5.4

Belize 24.4 Japan 4.7

Brazil 23.4 Germany 4.3

Morocco 20.8 Netherlands 3.4

Russia 18.9 United Kingdom 2.9

China 18.8 Sweden 2.8

Source: WHO, Global Status on Road Safety 2015

47

Alcohol related road traffic crashes,Per 100,000 of population

Source: WHO 2012

US 74.0 as of 2008

48

Road Traffic Mortality Trends (Developing Countries)

Rush hour can be chaotic in Delhi, India.

Currently there are 1,250,000

fatalities/yr., 50,000,000 injuries/yr.;

90% of the world’s road fatalities occur

in low/middle income countries though

they only have about half the world’s

vehicles

Half of those dying on the world’s

roads are “vulnerable users”

pedestrians, cyclists and motorcycles

WHO: “Without action, road traffic

crashes are predicted to rise to become

the 7th leading cause of death by 2030”

49Source: WHO 2004

50

Traffic Mortality Statistics and Trends in DevelopedCountries

Country 1979 Fatalities 2002 Fatalities Percent Change

United States 51,093 42,815 -16.20%

Great Britain 6,352 3,431 -46.00%

Canada 5,863 2,936 -49.90%

Australia 3,508 1,715 -51.10%

U.S. ranking has fallen from 1st to 18th over the last 30 years

51

With similar percentage improvement as Canada and the U.K., the U.S. could save 7,000 to 10,000 lives per year.

Some reasons U.S. is lagging

• Less seat belt use (84% in U.S. vs. 95% in Canada) and less motorcycle helmet use

• Not all U.S. states have primary seat belt laws

• Crumbling infrastructure, poorly maintained roads and bridges: 26% of U.S. roads and bridges are structurally deficient or obsolete

• Inconsistent enactment and enforcement of laws regarding driving under the influence of alcohol/drugs or distracted driving

Road Traffic Mortality Trends (Developed Countries)

52

• More SUVs, pick-up trucks, minivans (rollover danger, and these large vehicles pose considerably more risk to occupants of cars than other cars do)

• Less public transportation available

• Ill-considered new laws repealing mandatory helmet use by motorcyclists are guaranteeing many more deaths and injuries

o Only 19 U.S. states and the District of Columbia still require universal motorcycle helmets for all riders

o 47 states required helmets in 1975 when Federal Highway Finance was tied to helmet laws

• In the U.S. a total of 4,693 motorcyclists died in crashes in 2015. Motorcyclist deaths had been declining since the early 1980s but began to increase in 1998 and continued to increase through 2008. Motorcycle deaths accounted for 13 percent of all motor vehicle crash deaths in 2015 and were more than double the number of motorcyclist deaths in 1997.

Road Traffic Mortality Trends (Developed Countries)

53Source: The Association of Americans Resident Overseas, 2011

8.7 million Americans (excluding military) live in 160-plus

countries as of 2016 per US State department.

2011 Government Estimate of Overseas Americans by

region around the world

The estimated figures, by region, were:

Africa: 171,000

East Asia and Pacific: 864,000

Europe: 1,612,000

Near East: 870,000

South Central Asia: 212,000

Western Hemisphere: 2,591,000

For a total of 6,320,000

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World’s Top Travel Destinations 2015

Total US Resident trips abroad by year:

• 1990 – 44.6M

• 2000 – 61.3M

• 2009 – 61.4M

• 2015 – 74.0M

Country Million Country Million

France* 83.7 Turkey 39.8

United States 74.8 Germany 33.0

Spain 65.0 United Kingdom 32.6

China 55.6 Russia 29.8

Italy 48.6 Mexico 29.1

* France 2012 results. Source: UNWTO

55

U.S. Resident Travel Abroad (Outbound): 2006-2015

56

United States Resident Travel Abroad: 2015

International Trade Association – Office of Travel and Tourism Industries

Historical Visitation (Outbound) 2014 vs 2015 – One or More Nights

Region/Country 2014 (000) 2015 (000) % Change

(2015/2014)

TOTAL OUTBOUND 68,185 73,997 9%

Mexico 25,882 28,733 11%

Canada 11,523 12,475 8%

Overseas* 30,780 32,789 7%

Europe 10,804 11,378 5%

Caribbean 7,387 7,837 6%

Asia 5,694 6,066 7%

Central America 2,370 2,590 9%

South America 2,278 2,361 4%

Middle East 1,724 1,902 10%

Africa 893 951 7%

Oceania 585 656 12%

*Overseas includes

all countries except

Canada and Mexico

57

Top Destinations of U.S. Residents Traveling Abroad (Outbound) 2014 vs 2015

International Trade Association – Office

of Travel and Tourism Industries

58

International Processing and Administering Concerns

Where will exams and lab tests be completed?

Foreign language problems

APS time delays, bureaucracy, unavailable, non-existent

The one-paragraph “perfect health” APS

59

Passport is proof of citizenship

Place of birth information (U.S. or another country)

Green card, immigrant visa

Non-immigrant visa

No visa or wrong visa

Citizenship and Visas

Why knowing applicant’s citizenship and visa status helps in foreign risk evaluation

60

U.S. Resident Documents

1997 – 2010

1977 - 1997Employment Authorization Card

2010 – Current

Historical Green Card

61

U.S. Visa and I-94 Form

62

U.S. Non-Immigrant Visas

Complete list at U.S. Citizenship and Immigration Services website: USCIS and Non-immigrant Visas

Visa Description

B-1 & B-2 Temporary visitor for business or pleasure

E-1 & E-2 Treaty trader or investor

F-1 Academic Student

H-1B Specialty Occupations

L-1 Intra-company Transferee

63

• Travel legislation in California, Colorado, Connecticut, Florida, Illinois, Maryland, Massachusetts, Missouri, New Jersey, New York, Oklahoma, Tennessee and Washington

• Directives issued in Georgia

64

Application: place of birth, type of visa, address/residence, foreign travel questions

Foreign Travel Questionnaire: citizenship; visa type; anticipated foreign travel; list of specific countries to be visited; and duration, dates and purpose of travel

Inspection reports, telephone interviews, separate letter describing travel

Official Documents: copy of passport, green card, US visa, EAD, other US government issued documents on residential status

APS medical records (inoculations for travel, illnesses acquired abroad, mention of frequent travel or foreign residence)

Underwriting Foreign RiskKey information sources

65

Locations, dates & duration of foreign travel or residence

Medical risk: medical history, applicant’s age, current health

Occupation & work duties abroad, office or field work

Planned activities abroad: any hazardous activities such as mountain/rock climbing, scuba diving, aviation, etc.

Red Flags: financial, lack of candor, conflicting information, substance abuse, unfavorable MVR, other risks

Underwriting Foreign Risk

Risk Assessment

66

Short duration of foreign travel/residence

Travel is not immediate and not already under way

Only major urban areas visited

Purpose of travel is business, vacation, family visit

Traveler is 18-70 years of age

Life insurance application is for permanent or level term plan

Proposed insured is in good health

Lodging is at a hotel or relative’s home

Country of destination is considered relatively safe

Favorable Underwriting Factors

67

Long duration of foreign travel/residence

Anticipated travel is less than 60 days away or already under way

Travel is to rural and remote locations

Purpose of foreign travel/residence is to work as a missionary, journalist (132 deaths in 2009), relief worker, government official, public figure, etc.

Traveler is under 18 or over 70 years old

Application is for annual renewable term or short-term plan

Unfavorable Underwriting Factors

68

Amount of coverage requested appears excessive

Engaged in hazardous activities abroad

Quality and type of lodgings are uncertain

Destination is one or more high-risk countries

Traveler has serious pre-existing medical condition

Minimum (one month) premium payment made or selected

Recent immigrant with no available medical records and little or no comprehension of English

Unfavorable Underwriting Factors (cont’d.)

69

People residing in the US for less than 12 months prior to applying for life insurance

People residing in the US without an established physician

Older age recent immigrant to US (especially 60 years+)

Extra caution if applicant speaks little or no English

Financial justification is lacking

Grandparents who watch grandchildren and apply for $1M+

People crossing US/Mexican border multiple times/week

Red Flags of International Risk

70

There are 25 indicator variables that are included in this analysis as contributors to a country’s overall risk and are used to rank the 205 countries studied.

In the example here, the U.S. would have a rank of 39

RGA 2018 Foreign Risk Study Research Bulletin

Country summary

71

Country Study Rank Country Study Rank

Monaco 1 Denmark 20

Sweden 2 Belgium 21

Switzerland 3 Hong Kong 22

San Marino 4 Canada 23

Austria 5 Korea, South 24

Norway 6 Greece 25

Iceland 7 United Kingdom 26

Netherlands 8 Malta 27

France 9 Ireland 28

Japan 10 New Zealand 29

Australia 11 Guadeloupe 30

Italy 12 Portugal 31

Luxembourg 13 Czechia 32

Spain 14 Cyprus 33

Germany 15 Poland 34

Andorra 16 Bermuda 35

Finland 17 Slovakia 36

Liechtenstein 18 Slovenia 37

Singapore 19 Taiwan 38

RGA Foreign Risk Study Worldwide Country Rankings

72

Message to readers of article:

“Before you plan on visiting any of these places, get a life insurance policy.”

Photo of soldier with fire & smoke in background with caption:

• “Travelers are under the ongoing threat of kidnapping and assassination in Afghanistan.”

US Business Magazine Headline:

“Most Dangerous Destinations 2006”

Source: Forbes, Sophia Banay, February 22, 2006

73

Countries differ in many significant ways

Long-term foreign residence does matter

Most short-term foreign travel is low risk

A person’s health, age and planned activities abroad are important to consider in regard to foreign travel & residence risk

Foreign risk assessment should be based on relevant data & informed judgment. Avoid sensationalism & overgeneralization

More reliable record keeping and study of foreign risk are needed

Some valuable reference sources for international information follow

Conclusions

74

International Information Sources

U.S. State Department Travel Warnings at http://travel.state.gov/travel_warnings.html

U.S. State Department statistics non-natural deaths of US citizens abroad at http://travel.state.gov/family/family_issues/death/death_600.html

British Foreign & Commonwealth Office (Travel Advice) at www.fco.gov.uk

BBC News, Country Profiles, News Services

CNN.com International

Foreign Affairs Canada at www.voyage.gc.ca/consular_home-en.asp

CDC Health Information for international travel at www.cdc.gov/travel

Australian Department of Foreign Affairs & Trade at smartraveller.gov.au or www.dfat.gov.au

USCIS (U.S. visa information)

WHO (World Health Organization)

United Nations Human Development Reports

CIA World Factbook

www.rgare.com/underwritingconnection

75

Case 1 U.S. citizen, 35-year-old female who travels to Guatemala to volunteer as a nurse. Her stay is 1-3 weeks annually. She does not expect to visit non-urban areas.

Case 2 A 79-year-old male U.S. citizen applying for $750,000. Next month he is going on his honeymoon to Paris, France, for one week and then going on a safari trip in Kenya and Tanzania for two weeks.

Case 3 A 54-year-old male U.S. citizen seeking $1 million. He is an engineer with a multinational petroleum company. He is working and residing in Angola and travels back to the U.S. at least three times a year for visits.

Case 4 Male, age 56, Venezuelan citizen, seeking $2 million. He currently resides in Guyana, where the business he owns is located.

Case 5 Missionary living in Honduras, 41-year-old male. He makes two to three trips back to the States each year. He is a U.S. citizen and a resident of Honduras.

Case Studies

76

Case 6 $2 million of permanent coverage requested a 48 year old physician, born in Mexico. who is a U.S. permanent resident living in El Paso, Texas. She travels daily to Ciudad Juarez, Mexico where her office is located.

Case 7 A 29 year old male citizen of Brazil who came to USA on a student visa when he was 16 and over-stayed his visa. Working as a building contractor in the USA and has no plans to ever return to Brazil.

Case 8 Citizen/resident of Peru seeking $2 million coverage. Male, age 44, non-smoker, has congenital non-obstructive hypertrophic cardiomyopathy. He has regular check-ups with his cardiologist in Peru.

Case 9 $400,000 application on a U.S.-born 3-month-old baby girl who will be going to China to live with her grandparents for one year. Mother has $600,000 of coverage, father has $500,000 of coverage.

Case Studies

77

Case 10 A 66-year-old U.S. citizen seeking $2 million of coverage. Travels to Haiti with his church group every year to build water wells. He stays five to six days per trip.

Case 11 A 44-year-old female U.S. citizen seeks $250,000 term coverage. Retired and receiving disability due to a back injury. Income is from pension, Social Security disability and adoption stipend. Taking no medications. Plans two-week vacation to Liberia (Africa) in December.

Case 12 Female, age 51, U.S. citizen, has signed up for one of the first flights by Virgin Atlantic to go into outer space. The timing of this event is unknown and will occur in the future. Seeking $10 million of coverage.

Case Studies

78Thank you for your attention. Any questions?

“We shall not cease from exploration and the end of all our exploring will be to arrive where we started…and know the place for the first time.” T.S. Eliot

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