Form 720 for PCORI: A Filled-In Example
Here is a complete PCORI Form 720, filled in for one employer, using the June 2026 revision. The return below reports one fee and nothing else. It shows what each section holds and also what stays empty.
Everything about the employer is made up: Harbor Lane Manufacturing, Inc., its EIN, its address, its signer, and its numbers. Your entries depend on your own facts.
The employer behind the return
- A single employer with one self-insured major medical plan, so the employer is the plan sponsor.
- Calendar plan year, January 1 to December 31, 2025.
- Harbor Lane reports no other excise taxes, so this is its only Form 720 for the year.
- It uses the snapshot count method, on the 15th of the first month of each quarter.
- Its benefits manager prepares the return as an employee, so there is no paid preparer.
| Snapshot date | Lives covered, including dependents, COBRA, and retirees |
|---|---|
| January 15, 2025 | 604 |
| April 15, 2025 | 610 |
| July 15, 2025 | 615 |
| October 15, 2025 | 619 |
| Total | 2,448 |
| Average (2,448 ÷ 4) | 612 |
The plan year ended on or after October 1, 2025 and before October 1, 2026, so the rate is $3.84. The method itself is explained in our guide to counting covered lives.
Page 1: the header
| Box | Entry | Why |
|---|---|---|
| Name | Harbor Lane Manufacturing, Inc. | The plan sponsor, not a broker or administrator |
| Quarter ending | June 2026 | The fee goes on the second-quarter return. The instructions call for month and year. |
| Employer identification number | 00-0000000 (placeholder) | The sponsor's EIN. Enter the correct one. |
| Address | 100 Example Way, Sampletown | Street address, or a P.O. box if mail isn't delivered to the street address |
| Final return / Address change | Unchecked | Neither applies here |
| Part I, all lines and line 1 | Empty | No Part I taxes. Schedule A is only for Part I taxes. |
Part II: IRS No. 133
The PCORI lines sit at the top of Part II. Harbor Lane is self-insured, so it stays on the "applicable self-insured health plans" lines, and only one of the four has an entry.
| Line | Description on the form | (a) Avg. lives | (b) Rate | (c) Fee |
|---|---|---|---|---|
| 133(a) | Policy year ending before October 1, 2025 | Empty | $3.47 | Empty |
| 133(b) | Policy year ending October 1, 2025 to September 30, 2026 | Empty | $3.84 | Empty |
| 133(c) | Plan year ending before October 1, 2025 | Empty | $3.47 | Empty |
| 133(d) | Plan year ending October 1, 2025 to September 30, 2026 | 612 | $3.84 | $2,350.08 |
| 133 Tax column | Total of the fees above | $2,350.08 | ||
| Line 2 | Total of all amounts in Part II | $2,350.08 |
The math: 612 × $3.84 = $2,350.08. The IRS e-file rules check this in two ways. The fee on the line must equal lives multiplied by rate, and the IRS No. 133 tax must equal the sum of the four line fees. You can confirm the result in the PCORI fee calculator. Every other Part II line stays empty.
Part III and the signature block
| Line | What the line asks | Entry |
|---|---|---|
| 3 | Total tax: Part I line 1 plus Part II line 2 | $2,350.08 |
| 4 | Claims from Schedule C | Empty |
| 5 | Deposits made for the quarter | Empty (deposits aren't required for this fee) |
| 6 and 7 | Overpayment from previous quarters and the Form 720-X part of it | Empty |
| 8 | Add lines 5 and 6 | Empty |
| 9 | Add lines 4 and 8 | Empty |
| 10 | Balance due: line 3 minus line 9 | $2,350.08 |
| 11a to 11e | Overpayment and direct deposit details | Empty |
| Third Party Designee | Allow someone else to discuss this return with the IRS? | No |
| Sign Here | Signature, printed name, date, title, phone | A. Example, Benefits Manager, authorized by the company |
| Paid Preparer Use Only | Preparer name, signature, PTIN, firm details | Empty, as an employee prepared it |
The form must be signed by a person authorized by the entity. A benefits manager only works here if the company has authorized that person. If an outside firm had been paid to prepare it, the preparer would complete the last block with a PTIN and give Harbor Lane a copy. See our paid preparer guide for those entries.
Harbor Lane can pay the $2,350.08 by IRS Direct Pay, by EFTPS applied to Q2, by a debit or credit card through an IRS card service provider (who charges a fee), or by electronic funds withdrawal if filing electronically. Form 720-V is only needed if paying by check or money order. Schedules A, C, and T are not part of this return.
What would change on a different return?
| If Harbor Lane also... | The return would change like this |
|---|---|
| Had a second self-insured plan, with 40 lives and a plan year ended June 30, 2025 | Line 133(c): 40 × $3.47 = $138.80. The 133 Tax column, line 2, line 3, and line 10 become $2,488.88. |
| Had an HRA with the same sponsor and same plan year as the main plan | No separate fee. The two can be treated as one plan, and a person in both counts once. |
| Offered insured coverage as well as self-insured coverage | People covered solely under the insured option may be left out of the count, and the insurer has its own fee on the policy. |
| Filed Form 720 for another tax each quarter | Same lines for PCORI, with those other taxes added to the same return. Part I taxes would bring Schedule A in as well. |
| Had a credit on Schedule C | Line 4 would show the claims total, and line 10 would drop by that amount. |
Producing this same return online
If you e-file, you don't type into these boxes one by one. When you file the PCORI fee online with EasyFile720, you go through a guided filing from business details to submission. You enter the figures, such as Harbor Lane's 612, and the rates for the return are built in with the math calculated for you. Validations catch common mistakes before you submit. You sign electronically, pay $39.95 when you file, and get the IRS acknowledgment once it's accepted. The return stays saved in your account for next year. Do your count first, as the counting method and count stay your job, then begin on the PCORI fee filing page.
FAQ
Does the PCORI form have a special name or number?▼
No. There is no separate PCORI form. The fee is reported on Form 720, the Quarterly Federal Excise Tax Return, under IRS No. 133 in Part II.
Should we check the Final return box because we only file once a year?▼
The instructions don't say to check it for a PCORI-only filer, and they say no filing is required in other quarters unless you have other taxes. The fee recurs each year while your plan runs, so check with your adviser before marking a return final.
Do we attach our covered lives worksheet?▼
The form does not call for attaching it. Keep it with your records, since the instructions tell you to keep records that show the correct tax was paid.
Would this example look different for an insurance company?▼
Yes. An issuer of a specified health insurance policy would use line 133(a) or 133(b) instead of 133(c) or 133(d), and can also use the member months or state form counting methods.
File your PCORI fee online
Create a free account with no credit card and build your return. You pay $39.95 only when you file. EasyFile720 is an IRS-authorized e-file provider, and you get an acknowledgment when the IRS accepts your return.
Sources: Form 720 (Rev. June 2026); Instructions for Form 720 (Rev. June 2026); IRS PCORI Questions and Answers; IRS chart of coverage types; 26 CFR 46.4376-1; 720 Business Rules Publication 2026Q4 v1.0. General information, not tax advice. Confirm how the rules apply to you with a qualified advisor or the IRS.
