ACA Health Insurance Intake Form

Please complete this form so we can find the best Marketplace (ACA/Obamacare) health plan options for your family. All information is secure and used only for quoting purposes.

If you have questions, contact Steven Dao – The Dao Agency at Steven@TheDaoAgencyATL.com or 678-801-8001.

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Full Name(Required)

First Last

Email(Required)

Phone Number(Required)

Gender(Required)

Date Of Birth(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Are You A Tobacco User?(Required)

Yes

Are You A U.S. Citizen or Lawful Resident?(Required)

Yes

Other

If Other, Please Specify:

Do you currently have any health insurance coverage?

No, I do not

Yes, through employer

Yes, through Marketplace

Yes, Through Medicaid/Medicare

Other

If Other, Please Specify:

If yes, please provide your current insurance provider and policy number.

What type of coverage are you looking for?(Required)

Individual

Family

Dental

Vision

Prescription Drug

About The Dao Agency

We’re a Georgia-based agency helping families and individuals with insurance and real estate. We started because we saw too many people getting pushed into plans they didn’t need or deals that didn’t make sense. Our approach is simple: listen to what you actually need, show you the options, and help you make the right call. No pressure – just expert guidance when you need it most.

-Steven Dao, Founder

Our Services

Health Insurance

Car Insurance

Real Estate

Resources

ACA Health Insurance Intake Form

Get Started

The Dao Agency – Insurance & Real Estate Solutions