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Atlas Contract Number
Must 8 digits long containing only numbers.
UPCIC Policy Number
Must be 9 or 12 digits long adhering to one of the following formats: XXX-XXX-XXX or XXXX-XXXX-XXXX or XXXXXXXXX or XXXXXXXXXXXXX.
Bank Account Holder
Must must have a first & last name and may contain only letters, spaces, and apostrophes.
Checking Account Number
Must be at least 5 digits long and may contain only numbers.
Routing Number
Must be 9 digits long and may contain only numbers. Further, it must belong to a bank which participates in the ACH program.
Payment Amount
* Please include late fee if payment is made after five day grace period.
Must be a positive, non-zero amount containing only numbers.
Confirmation Number: