rpama-ext.safeco.com Open in urlscan Pro
23.13.160.99 Public Scan

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URL:
https://rpama-ext.safeco.com/
Submission: On December 08 via automatic, source certstream-suspicious (December 8th 2024, 10:57:00 am UTC) — Scanned from US

Form analysis
1 forms found in the DOM

POST ac.html

<form data-dojo-attach-point="containerNode" data-dojo-attach-event="onreset:_onReset,onsubmit:_onSubmit" id="dijit_form_Form_0" target="autoCompleteSupportIframe" method="post" action="ac.html" widgetid="dijit_form_Form_0">
  <div class="section accountTypeSelectionSection displayNone">
    <div class="header accountTypeSelectionHeader">New Payment Account</div>
    <div class="field"><label for="accountType" class="fieldLabel"><span id="_accountTypeFieldLabelText" class="fieldLabelText">Account Type</span><span id="_accountTypeFieldLabelHelp" class="fieldLabelHelp displayNone"></span></label>
      <div class="fieldInput"><select name="accountType" data-dojo-attach-point="containerNode,focusNode" data-dojo-attach-event="onchange: _onChange" class="input accountTypeInput dijitSelect" tabindex="0" autocomplete="off" aria-required="false"
          aria-invalid="false" id="accountType" aria-describedby="_accountTypeFieldLabelHelp" widgetid="accountType" aria-disabled="false">
          <option value="">- Please Select -</option>
          <option value="checking">Checking Account</option>
          <option value="savings">Savings Account</option>
          <option value="credit">Credit Card</option>
          <option value="debit">Debit Card</option>
        </select><span class="fieldInputError"></span></div>
    </div>
  </div>
  <div class="section paymentAccountSection">
    <div class="header paymentAccountHeader">Credit Card Information</div>
    <div class="field displayNone"><label for="nameOptions" class="fieldLabel"><span id="_nameOptionsFieldLabelText" class="fieldLabelText"></span><span id="_nameOptionsFieldLabelHelp" class="fieldLabelHelp"></span></label>
      <div class="fieldInput"><select name="nameOptions" data-dojo-attach-point="containerNode,focusNode" data-dojo-attach-event="onchange: _onChange" class="input nameOptionsInput dijitSelect dijitSelectDisabled dijitDisabled" tabindex="-1"
          autocomplete="" aria-required="false" aria-invalid="false" id="nameOptions" aria-describedby="_nameOptionsFieldLabelHelp" widgetid="nameOptions" disabled="" aria-disabled="true">
          <option value="">- Please Select -</option>
        </select><span class="fieldInputError"></span></div>
    </div>
    <div id="cardGroup" class="fieldGroup">
      <div class="field"><label for="firstName" class="fieldLabel"><span id="_cardholderNameFieldLabelText" class="fieldLabelText">Cardholder Name</span><span id="_cardholderNameFieldLabelHelp" class="fieldLabelHelp">(As it appears on
            card)</span></label>
        <div class="fieldInput"><label id="_firstNameInputLabel" for="firstName" class="fieldLabelHidden">First Name</label>
          <div class="dijit dijitReset dijitInline dijitLeft input firstNameInput dijitTextBox dijitValidationTextBox dijitTextBoxIncomplete dijitValidationTextBoxIncomplete dijitIncomplete" id="widget_firstName" role="presentation"
            widgetid="firstName">
            <div class="dijitReset dijitValidationContainer"><input class="dijitReset dijitInputField dijitValidationIcon dijitValidationInner" value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div>
            <div class="dijitReset dijitInputField dijitInputContainer"><input class="dijitReset dijitInputInner" data-dojo-attach-point="textbox,focusNode" autocomplete="off" name="firstName" type="text" tabindex="0" aria-required="true"
                maxlength="35" id="firstName" aria-labelledby="_cardholderNameFieldLabelText _firstNameInputLabel" aria-describedby="_cardholderNameFieldLabelHelp" value="" aria-invalid="true" aria-disabled="false"><span
                class="dijitPlaceHolder dijitInputField">First Name</span></div>
          </div><label id="_middleInitialInputLabel" for="middleInitial" class="fieldLabelHidden">Middle Initial</label>
          <div class="dijit dijitReset dijitInline dijitLeft dijitTextBox dijitValidationTextBox input middleInitialInput" id="widget_middleInitial" role="presentation" widgetid="middleInitial">
            <div class="dijitReset dijitValidationContainer"><input class="dijitReset dijitInputField dijitValidationIcon dijitValidationInner" value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div>
            <div class="dijitReset dijitInputField dijitInputContainer"><input class="dijitReset dijitInputInner" data-dojo-attach-point="textbox,focusNode" autocomplete="off" name="middleInitial" type="text" tabindex="0" aria-required="false"
                maxlength="1" id="middleInitial" aria-labelledby="_cardholderNameFieldLabelText _middleInitialInputLabel" aria-describedby="_cardholderNameFieldLabelHelp" value="" aria-invalid="false" aria-disabled="false"><span
                class="dijitPlaceHolder dijitInputField">MI</span></div>
          </div><label id="_lastNameInputLabel" for="lastName" class="fieldLabelHidden">Last Name</label>
          <div class="dijit dijitReset dijitInline dijitLeft input lastNameInput dijitTextBox dijitValidationTextBox dijitTextBoxIncomplete dijitValidationTextBoxIncomplete dijitIncomplete" id="widget_lastName" role="presentation"
            widgetid="lastName">
            <div class="dijitReset dijitValidationContainer"><input class="dijitReset dijitInputField dijitValidationIcon dijitValidationInner" value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div>
            <div class="dijitReset dijitInputField dijitInputContainer"><input class="dijitReset dijitInputInner" data-dojo-attach-point="textbox,focusNode" autocomplete="off" name="lastName" type="text" tabindex="0" aria-required="true"
                maxlength="35" id="lastName" aria-labelledby="_cardholderNameFieldLabelText _lastNameInputLabel" aria-describedby="_cardholderNameFieldLabelHelp" value="" aria-invalid="true" aria-disabled="false"><span
                class="dijitPlaceHolder dijitInputField">Last Name</span></div>
          </div><span class="fieldInputError"></span>
        </div>
      </div>
      <div class="field"><label for="cardNumber" class="fieldLabel"><span id="_cardNumberFieldLabelText" class="fieldLabelText">Card Number</span><span id="_cardNumberFieldLabelHelp" class="fieldLabelHelp">(No dashes or spaces)</span></label>
        <div class="fieldInput">
          <div class="dijit dijitReset dijitInline dijitLeft input cardNumberInput dijitTextBox dijitValidationTextBox dijitTextBoxIncomplete dijitValidationTextBoxIncomplete dijitIncomplete" id="widget_cardNumber" role="presentation"
            widgetid="cardNumber">
            <div class="dijitReset dijitValidationContainer"><input class="dijitReset dijitInputField dijitValidationIcon dijitValidationInner" value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div>
            <div class="dijitReset dijitInputField dijitInputContainer"><input class="dijitReset dijitInputInner" data-dojo-attach-point="textbox,focusNode" autocomplete="off" name="cardNumber" type="tel" tabindex="0" aria-required="true"
                maxlength="16" id="cardNumber" aria-describedby="_cardNumberFieldLabelHelp" value="" aria-invalid="true" aria-disabled="false"><span class="dijitPlaceHolder dijitInputField" style="display: none;"></span></div>
          </div><img id="visaImg" src="piFinPmtAcctMiniApp/images/visa.png?build=FINRPAMADJ_2024_10_WR1_B001" alt="Visa" class="cardImg"><img id="mastercardImg" src="piFinPmtAcctMiniApp/images/masterCard.png?build=FINRPAMADJ_2024_10_WR1_B001"
            alt="MasterCard" class="cardImg"><img id="discoverImg" src="piFinPmtAcctMiniApp/images/discover.png?build=FINRPAMADJ_2024_10_WR1_B001" alt="Discover" class="cardImg"><img id="amexImg"
            src="piFinPmtAcctMiniApp/images/americanExpress.png?build=FINRPAMADJ_2024_10_WR1_B001" alt="American Express" class="cardImg"><span class="fieldInputError"></span>
        </div>
      </div>
      <div class="field"><label for="expirationMonth" class="fieldLabel"><span id="_expirationDateFieldLabelText" class="fieldLabelText">Expiration Date</span><span id="_expirationDateFieldLabelHelp" class="fieldLabelHelp displayNone"></span></label>
        <div class="fieldInput"><label id="_expirationMonthInputLabel" for="expirationMonth" class="fieldLabelHidden">Month</label><select name="expirationMonth" data-dojo-attach-point="containerNode,focusNode"
            data-dojo-attach-event="onchange: _onChange" class="dijitSelect input expirationMonthInput dijitSelectIncomplete dijitIncomplete" tabindex="0" autocomplete="off" aria-required="true" aria-invalid="true" id="expirationMonth"
            aria-labelledby="_expirationDateFieldLabelText _expirationMonthInputLabel" aria-describedby="_expirationDateFieldLabelHelp" widgetid="expirationMonth" aria-disabled="false">
            <option value="">Month</option>
            <option value="01">01</option>
            <option value="02">02</option>
            <option value="03">03</option>
            <option value="04">04</option>
            <option value="05">05</option>
            <option value="06">06</option>
            <option value="07">07</option>
            <option value="08">08</option>
            <option value="09">09</option>
            <option value="10">10</option>
            <option value="11">11</option>
            <option value="12">12</option>
          </select><label id="_expirationYearInputLabel" for="expirationYear" class="fieldLabelHidden">Year</label><select name="expirationYear" data-dojo-attach-point="containerNode,focusNode" data-dojo-attach-event="onchange: _onChange"
            class="dijitSelect input expirationYearInput dijitSelectIncomplete dijitIncomplete" tabindex="0" autocomplete="off" aria-required="true" aria-invalid="true" id="expirationYear"
            aria-labelledby="_expirationDateFieldLabelText _expirationYearInputLabel" aria-describedby="_expirationDateFieldLabelHelp" widgetid="expirationYear" aria-disabled="false">
            <option value="">Year</option>
            <option value="2024">2024</option>
            <option value="2025">2025</option>
            <option value="2026">2026</option>
            <option value="2027">2027</option>
            <option value="2028">2028</option>
            <option value="2029">2029</option>
            <option value="2030">2030</option>
            <option value="2031">2031</option>
            <option value="2032">2032</option>
            <option value="2033">2033</option>
            <option value="2034">2034</option>
            <option value="2035">2035</option>
            <option value="2036">2036</option>
            <option value="2037">2037</option>
            <option value="2038">2038</option>
          </select><span class="fieldInputError"></span></div>
      </div>
      <div class="field"><label for="securityCode" class="fieldLabel"><span id="_securityCodeFieldLabelText" class="fieldLabelText">Security Code</span><span id="_securityCodeFieldLabelHelp" class="fieldLabelHelp displayNone"></span></label>
        <div class="fieldInput">
          <div class="dijit dijitReset dijitInline dijitLeft input securityCodeInput dijitTextBox dijitValidationTextBox dijitTextBoxIncomplete dijitValidationTextBoxIncomplete dijitIncomplete" id="widget_securityCode" role="presentation"
            widgetid="securityCode">
            <div class="dijitReset dijitValidationContainer"><input class="dijitReset dijitInputField dijitValidationIcon dijitValidationInner" value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div>
            <div class="dijitReset dijitInputField dijitInputContainer"><input class="dijitReset dijitInputInner" data-dojo-attach-point="textbox,focusNode" autocomplete="off" name="securityCode" type="tel" tabindex="0" aria-required="true"
                maxlength="4" id="securityCode" aria-describedby="_securityCodeFieldLabelHelp" value="" aria-invalid="true" aria-disabled="false"><span class="dijitPlaceHolder dijitInputField" style="display: none;"></span></div>
          </div>
          <div class="displayNone">3-digit number on back of card<img src="piFinPmtAcctMiniApp/images/security-code-3-digits-back.png?build=FINRPAMADJ_2024_10_WR1_B001"></div>
          <div class="displayNone">4-digit number on FRONT of card<img src="piFinPmtAcctMiniApp/images/security-code-4-digits-front.png?build=FINRPAMADJ_2024_10_WR1_B001"></div><span class="fieldInputError"></span>
        </div>
      </div>
    </div>
    <div id="eftGroup" class="fieldGroup displayNone">
      <div class="field"><label for="eftFirstName" class="fieldLabel"><span id="_eftNameFieldLabelText" class="fieldLabelText">Account Holder Name</span><span id="_eftNameFieldLabelHelp" class="fieldLabelHelp displayNone"></span></label>
        <div class="fieldInput"><label id="_eftFirstNameInputLabel" for="eftFirstName" class="fieldLabelHidden">First Name</label>
          <div class="dijit dijitReset dijitInline dijitLeft input firstNameInput dijitTextBox dijitValidationTextBox" id="widget_eftFirstName" role="presentation" widgetid="eftFirstName">
            <div class="dijitReset dijitValidationContainer"><input class="dijitReset dijitInputField dijitValidationIcon dijitValidationInner" value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div>
            <div class="dijitReset dijitInputField dijitInputContainer"><input class="dijitReset dijitInputInner" data-dojo-attach-point="textbox,focusNode" autocomplete="off" name="eftFirstName" type="text" tabindex="0" aria-required="false"
                maxlength="35" id="eftFirstName" aria-labelledby="_eftNameFieldLabelText _eftFirstNameInputLabel" aria-describedby="_eftNameFieldLabelHelp" value="" aria-invalid="false" aria-disabled="false"><span
                class="dijitPlaceHolder dijitInputField">First Name</span></div>
          </div><label id="_eftMiddleInitialInputLabel" for="eftMiddleInitial" class="fieldLabelHidden">Middle Initial</label>
          <div class="dijit dijitReset dijitInline dijitLeft dijitTextBox dijitValidationTextBox input middleInitialInput" id="widget_eftMiddleInitial" role="presentation" widgetid="eftMiddleInitial">
            <div class="dijitReset dijitValidationContainer"><input class="dijitReset dijitInputField dijitValidationIcon dijitValidationInner" value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div>
            <div class="dijitReset dijitInputField dijitInputContainer"><input class="dijitReset dijitInputInner" data-dojo-attach-point="textbox,focusNode" autocomplete="off" name="eftMiddleInitial" type="text" tabindex="0" aria-required="false"
                maxlength="1" id="eftMiddleInitial" aria-labelledby="_eftNameFieldLabelText _eftMiddleInitialInputLabel" aria-describedby="_eftNameFieldLabelHelp" value="" aria-invalid="false" aria-disabled="false"><span
                class="dijitPlaceHolder dijitInputField">MI</span></div>
          </div><label id="_eftLastNameInputLabel" for="eftLastName" class="fieldLabelHidden">Last Name</label>
          <div class="dijit dijitReset dijitInline dijitLeft input lastNameInput dijitTextBox dijitValidationTextBox" id="widget_eftLastName" role="presentation" widgetid="eftLastName">
            <div class="dijitReset dijitValidationContainer"><input class="dijitReset dijitInputField dijitValidationIcon dijitValidationInner" value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div>
            <div class="dijitReset dijitInputField dijitInputContainer"><input class="dijitReset dijitInputInner" data-dojo-attach-point="textbox,focusNode" autocomplete="off" name="eftLastName" type="text" tabindex="0" aria-required="false"
                maxlength="35" id="eftLastName" aria-labelledby="_eftNameFieldLabelText _eftLastNameInputLabel" aria-describedby="_eftNameFieldLabelHelp" value="" aria-invalid="false" aria-disabled="false"><span
                class="dijitPlaceHolder dijitInputField">Last Name</span></div>
          </div><span class="fieldInputError"></span>
        </div>
      </div>
      <div class="field"><label for="bankRoutingNumber" class="fieldLabel"><span id="_bankRoutingNumberFieldLabelText" class="fieldLabelText">Bank Routing Number</span><span id="_bankRoutingNumberFieldLabelHelp"
            class="fieldLabelHelp displayNone"></span></label>
        <div class="fieldInput">
          <div class="dijit dijitReset dijitInline dijitLeft input bankRoutingNumberInput dijitTextBox dijitValidationTextBox" id="widget_bankRoutingNumber" role="presentation" widgetid="bankRoutingNumber">
            <div class="dijitReset dijitValidationContainer"><input class="dijitReset dijitInputField dijitValidationIcon dijitValidationInner" value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div>
            <div class="dijitReset dijitInputField dijitInputContainer"><input class="dijitReset dijitInputInner" data-dojo-attach-point="textbox,focusNode" autocomplete="off" name="bankRoutingNumber" type="tel" tabindex="0" aria-required="false"
                maxlength="9" id="bankRoutingNumber" aria-describedby="_bankRoutingNumberFieldLabelHelp" value="" aria-invalid="false" aria-disabled="false"><span class="dijitPlaceHolder dijitInputField" style="display: none;"></span></div>
          </div>
          <div class="eftBankName"></div><span class="fieldInputError"></span>
        </div>
      </div>
      <div class="field"><label for="bankAccountNumber" class="fieldLabel"><span id="_bankAccountNumberFieldLabelText" class="fieldLabelText">Bank Account Number</span><span id="_bankAccountNumberFieldLabelHelp"
            class="fieldLabelHelp displayNone"></span></label>
        <div class="fieldInput">
          <div class="dijit dijitReset dijitInline dijitLeft input bankAccountNumberInput dijitTextBox dijitValidationTextBox" id="widget_bankAccountNumber" role="presentation" widgetid="bankAccountNumber">
            <div class="dijitReset dijitValidationContainer"><input class="dijitReset dijitInputField dijitValidationIcon dijitValidationInner" value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div>
            <div class="dijitReset dijitInputField dijitInputContainer"><input class="dijitReset dijitInputInner" data-dojo-attach-point="textbox,focusNode" autocomplete="off" name="bankAccountNumber" type="tel" tabindex="0" aria-required="false"
                maxlength="17" id="bankAccountNumber" aria-describedby="_bankAccountNumberFieldLabelHelp" value="" aria-invalid="false" aria-disabled="false"><span class="dijitPlaceHolder dijitInputField" style="display: none;"></span></div>
          </div><span class="fieldInputError"></span>
        </div>
      </div>
      <div class="field checkSample"><img src="piFinPmtAcctMiniApp/images/checking-account.jpg?build=FINRPAMADJ_2024_10_WR1_B001"></div>
    </div>
    <div class="field"><label for="saveAccount" class="fieldLabel"><span id="_saveAccountFieldLabelText" class="fieldLabelText">Save Account For Future Use</span><span id="_saveAccountFieldLabelHelp" class="fieldLabelHelp displayNone"></span></label>
      <div class="fieldInput">
        <div class="dijit dijitReset dijitInline dijitCheckBox input saveAccountInput" role="presentation" widgetid="saveAccount"><input name="saveAccount" type="checkbox" role="checkbox" aria-checked="false" class="dijitReset dijitCheckBoxInput"
            data-dojo-attach-point="focusNode" data-dojo-attach-event="ondijitclick:_onClick" value="on" tabindex="0" id="saveAccount" aria-describedby="_saveAccountFieldLabelHelp" autocomplete="off" aria-disabled="false" placeholder="undefined"
            style="user-select: none;"></div><span class="fieldInputError"></span>
      </div>
    </div>
    <div class="field displayNone"><label for="accountNickName" class="fieldLabel"><span id="_accountNickNameFieldLabelText" class="fieldLabelText">Account Nickname</span><span id="_accountNickNameFieldLabelHelp"
          class="fieldLabelHelp">(Optional)</span></label>
      <div class="fieldInput">
        <div class="dijit dijitReset dijitInline dijitLeft input accountNickNameInput dijitTextBox dijitValidationTextBox dijitTextBoxDisabled dijitValidationTextBoxDisabled dijitDisabled" id="widget_accountNickName" role="presentation"
          widgetid="accountNickName">
          <div class="dijitReset dijitValidationContainer"><input class="dijitReset dijitInputField dijitValidationIcon dijitValidationInner" value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div>
          <div class="dijitReset dijitInputField dijitInputContainer"><input class="dijitReset dijitInputInner" data-dojo-attach-point="textbox,focusNode" autocomplete="off" name="accountNickName" type="text" tabindex="-1" aria-required="false"
              maxlength="100" id="accountNickName" aria-describedby="_accountNickNameFieldLabelHelp" value="" aria-invalid="false" aria-disabled="true" disabled=""><span class="dijitPlaceHolder dijitInputField" style="display: none;"></span></div>
        </div><span class="fieldInputError"></span>
      </div>
    </div>
  </div>
  <div class="section billingAddressSection">
    <div class="header billingAddressHeader">Billing Address</div>
    <div class="field displayNone"><label for="addressOptions" class="fieldLabel"><span id="_addressOptionsFieldLabelText" class="fieldLabelText"></span><span id="_addressOptionsFieldLabelHelp" class="fieldLabelHelp"></span></label>
      <div class="fieldInput"><select name="addressOptions" data-dojo-attach-point="containerNode,focusNode" data-dojo-attach-event="onchange: _onChange" class="input addressOptionsInput dijitSelect dijitSelectDisabled dijitDisabled" tabindex="-1"
          autocomplete="" aria-required="false" aria-invalid="false" id="addressOptions" aria-describedby="_addressOptionsFieldLabelHelp" widgetid="addressOptions" disabled="" aria-disabled="true">
          <option value="">- Please Select -</option>
        </select><span class="fieldInputError"></span></div>
    </div>
    <div class="field"><label for="streetAddress1" class="fieldLabel"><span id="_streetAddress1FieldLabelText" class="fieldLabelText">Street Address 1</span><span id="_streetAddress1FieldLabelHelp" class="fieldLabelHelp displayNone"></span></label>
      <div class="fieldInput">
        <div class="dijit dijitReset dijitInline dijitLeft input streetAddress1Input dijitTextBox dijitValidationTextBox dijitTextBoxIncomplete dijitValidationTextBoxIncomplete dijitIncomplete" id="widget_streetAddress1" role="presentation"
          widgetid="streetAddress1">
          <div class="dijitReset dijitValidationContainer"><input class="dijitReset dijitInputField dijitValidationIcon dijitValidationInner" value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div>
          <div class="dijitReset dijitInputField dijitInputContainer"><input class="dijitReset dijitInputInner" data-dojo-attach-point="textbox,focusNode" autocomplete="off" name="streetAddress1" type="text" tabindex="0" aria-required="true"
              maxlength="30" id="streetAddress1" aria-describedby="_streetAddress1FieldLabelHelp" value="" aria-invalid="true" aria-disabled="false"><span class="dijitPlaceHolder dijitInputField" style="display: none;"></span></div>
        </div><span class="fieldInputError"></span>
      </div>
    </div>
    <div class="field"><label for="streetAddress2" class="fieldLabel"><span id="_streetAddress2FieldLabelText" class="fieldLabelText">Street Address 2</span><span id="_streetAddress2FieldLabelHelp" class="fieldLabelHelp">(Optional)</span></label>
      <div class="fieldInput">
        <div class="dijit dijitReset dijitInline dijitLeft dijitTextBox dijitValidationTextBox input streetAddress2Input" id="widget_streetAddress2" role="presentation" widgetid="streetAddress2">
          <div class="dijitReset dijitValidationContainer"><input class="dijitReset dijitInputField dijitValidationIcon dijitValidationInner" value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div>
          <div class="dijitReset dijitInputField dijitInputContainer"><input class="dijitReset dijitInputInner" data-dojo-attach-point="textbox,focusNode" autocomplete="off" name="streetAddress2" type="text" tabindex="0" aria-required="false"
              maxlength="30" id="streetAddress2" aria-describedby="_streetAddress2FieldLabelHelp" value="" aria-invalid="false" aria-disabled="false"><span class="dijitPlaceHolder dijitInputField" style="display: none;"></span></div>
        </div><span class="fieldInputError"></span>
      </div>
    </div>
    <div class="field"><label for="city" class="fieldLabel"><span id="_cityFieldLabelText" class="fieldLabelText">City</span><span id="_cityFieldLabelHelp" class="fieldLabelHelp displayNone"></span></label>
      <div class="fieldInput">
        <div class="dijit dijitReset dijitInline dijitLeft input cityInput dijitTextBox dijitValidationTextBox dijitTextBoxIncomplete dijitValidationTextBoxIncomplete dijitIncomplete" id="widget_city" role="presentation" widgetid="city">
          <div class="dijitReset dijitValidationContainer"><input class="dijitReset dijitInputField dijitValidationIcon dijitValidationInner" value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div>
          <div class="dijitReset dijitInputField dijitInputContainer"><input class="dijitReset dijitInputInner" data-dojo-attach-point="textbox,focusNode" autocomplete="off" name="city" type="text" tabindex="0" aria-required="true" maxlength="20"
              id="city" aria-describedby="_cityFieldLabelHelp" value="" aria-invalid="true" aria-disabled="false"><span class="dijitPlaceHolder dijitInputField" style="display: none;"></span></div>
        </div><span class="fieldInputError"></span>
      </div>
    </div>
    <div class="field"><label for="state" class="fieldLabel"><span id="_stateFieldLabelText" class="fieldLabelText">State</span><span id="_stateFieldLabelHelp" class="fieldLabelHelp displayNone"></span></label>
      <div class="fieldInput"><select name="state" data-dojo-attach-point="containerNode,focusNode" data-dojo-attach-event="onchange: _onChange" class="dijitSelect input stateInput dijitSelectIncomplete dijitIncomplete" tabindex="0"
          autocomplete="off" aria-required="true" aria-invalid="true" id="state" aria-describedby="_stateFieldLabelHelp" widgetid="state" aria-disabled="false">
          <option value="">- Please Select -</option>
          <option value="AL">AL</option>
          <option value="AK">AK</option>
          <option value="AZ">AZ</option>
          <option value="AR">AR</option>
          <option value="CA">CA</option>
          <option value="CO">CO</option>
          <option value="CT">CT</option>
          <option value="DE">DE</option>
          <option value="DC">DC</option>
          <option value="FL">FL</option>
          <option value="GA">GA</option>
          <option value="HI">HI</option>
          <option value="ID">ID</option>
          <option value="IL">IL</option>
          <option value="IN">IN</option>
          <option value="IA">IA</option>
          <option value="KS">KS</option>
          <option value="KY">KY</option>
          <option value="LA">LA</option>
          <option value="ME">ME</option>
          <option value="MD">MD</option>
          <option value="MA">MA</option>
          <option value="MI">MI</option>
          <option value="MN">MN</option>
          <option value="MS">MS</option>
          <option value="MO">MO</option>
          <option value="MT">MT</option>
          <option value="NE">NE</option>
          <option value="NV">NV</option>
          <option value="NH">NH</option>
          <option value="NJ">NJ</option>
          <option value="NM">NM</option>
          <option value="NY">NY</option>
          <option value="NC">NC</option>
          <option value="ND">ND</option>
          <option value="OH">OH</option>
          <option value="OK">OK</option>
          <option value="OR">OR</option>
          <option value="PA">PA</option>
          <option value="RI">RI</option>
          <option value="SC">SC</option>
          <option value="SD">SD</option>
          <option value="TN">TN</option>
          <option value="TX">TX</option>
          <option value="UT">UT</option>
          <option value="VT">VT</option>
          <option value="VA">VA</option>
          <option value="WA">WA</option>
          <option value="WV">WV</option>
          <option value="WI">WI</option>
          <option value="WY">WY</option>
        </select><span class="fieldInputError"></span></div>
    </div>
    <div class="field"><label for="zipCode" class="fieldLabel"><span id="_zipCodeFieldLabelText" class="fieldLabelText">Zip Code</span><span id="_zipCodeFieldLabelHelp" class="fieldLabelHelp displayNone"></span></label>
      <div class="fieldInput">
        <div class="dijit dijitReset dijitInline dijitLeft input zipCodeInput dijitTextBox dijitValidationTextBox dijitTextBoxIncomplete dijitValidationTextBoxIncomplete dijitIncomplete" id="widget_zipCode" role="presentation" widgetid="zipCode">
          <div class="dijitReset dijitValidationContainer"><input class="dijitReset dijitInputField dijitValidationIcon dijitValidationInner" value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div>
          <div class="dijitReset dijitInputField dijitInputContainer"><input class="dijitReset dijitInputInner" data-dojo-attach-point="textbox,focusNode" autocomplete="off" name="zipCode" type="tel" tabindex="0" aria-required="true" maxlength="5"
              id="zipCode" aria-describedby="_zipCodeFieldLabelHelp" value="" aria-invalid="true" aria-disabled="false"><span class="dijitPlaceHolder dijitInputField" style="display: none;"></span></div>
        </div><span class="fieldInputError"></span>
      </div>
    </div>
  </div>
  <div class="section userActionSection"><span class="dijit dijitReset dijitInline dijitButton button authorizeButton displayNone" role="presentation" widgetid="dijit_form_Button_0"><span class="dijitReset dijitInline dijitButtonNode"
        data-dojo-attach-event="ondijitclick:__onClick" role="presentation"><span class="dijitReset dijitStretch dijitButtonContents" data-dojo-attach-point="titleNode,focusNode" role="button" aria-labelledby="dijit_form_Button_0_label" tabindex="0"
          id="dijit_form_Button_0" style="user-select: none;"><span class="dijitReset dijitInline dijitIcon dijitNoIcon" data-dojo-attach-point="iconNode"></span><span class="dijitReset dijitToggleButtonIconChar">●</span><span
            class="dijitReset dijitInline dijitButtonText" id="dijit_form_Button_0_label" data-dojo-attach-point="containerNode">Validate Account</span></span></span><input type="button" value="" class="dijitOffScreen"
        data-dojo-attach-event="onclick:_onClick" tabindex="-1" role="presentation" aria-hidden="true" data-dojo-attach-point="valueNode"></span><span
      class="dijit dijitReset dijitInline dijitButton button resetButton dijitButtonDisabled dijitDisabled displayNone" role="presentation" widgetid="dijit_form_Button_1"><span class="dijitReset dijitInline dijitButtonNode"
        data-dojo-attach-event="ondijitclick:__onClick" role="presentation"><span class="dijitReset dijitStretch dijitButtonContents" data-dojo-attach-point="titleNode,focusNode" role="button" aria-labelledby="dijit_form_Button_1_label" tabindex="-1"
          id="dijit_form_Button_1" aria-disabled="true" style="user-select: none;"><span class="dijitReset dijitInline dijitIcon dijitNoIcon" data-dojo-attach-point="iconNode"></span><span class="dijitReset dijitToggleButtonIconChar">●</span><span
            class="dijitReset dijitInline dijitButtonText" id="dijit_form_Button_1_label" data-dojo-attach-point="containerNode">Update Account</span></span></span><input type="button" value="" class="dijitOffScreen"
        data-dojo-attach-event="onclick:_onClick" tabindex="-1" role="presentation" aria-hidden="true" data-dojo-attach-point="valueNode" disabled=""></span></div><button id="autoCompleteSubmitBtn" name="autoCompleteSubmitBtn" type="submit"
    class="displayNone"></button>
</form>

Text Content

New Payment Account
Account Type
- Please Select -Checking AccountSavings AccountCredit CardDebit Card
Credit Card Information
- Please Select -
Cardholder Name(As it appears on card)
First Name
First Name
Middle Initial
MI
Last Name
Last Name
Card Number(No dashes or spaces)

Expiration Date
MonthMonth010203040506070809101112YearYear202420252026202720282029203020312032203320342035203620372038
Security Code
3-digit number on back of card
4-digit number on FRONT of card
Account Holder Name
First Name
First Name
Middle Initial
MI
Last Name
Last Name
Bank Routing Number

Bank Account Number


Save Account For Future Use

Account Nickname(Optional)

Billing Address
- Please Select -
Street Address 1

Street Address 2(Optional)

City

State
- Please Select
-ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
Zip Code

●Validate Account●Update Account

rpama-ext.safeco.com Open in urlscan Pro 23.13.160.99 Public Scan

Form analysis 1 forms found in the DOM

POST ac.html

Text Content

rpama-ext.safeco.com Open in urlscan Pro
23.13.160.99 Public Scan

Form analysis
1 forms found in the DOM